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DENTAL 
MATERIA  MEDICA  AND  THERAPEUTICS 


PRINZ 


DENTAL 

MATERIA     MEDIGA 

AND 

THERAPEUTICS 


With  Special  Reference  to  the  Rational  Application  of  Remedial 
Measures  to  Dental  Diseases 


A  Text  Book  for  Students  and  Practitioners 

BY 

HERMANN  PRINZ,  A.M.,  D.D.S.,  M.D. 

Professor    of    Materia    Medica   and    Therapeutics,    The    Thomas    W.    Evans    Museum    and 

Dental   Institute   School   of   Dentistry   University    of   Pennsylvania;    formerly 

Professor    of    Materia    Medica,    Therapeutics,    and    Pathology,    and 

Director   of  the    Research   Laboratory,    Washington 

University    Dental    School,    St.    Louis 


FIFTH  EDITION 

ENLARGED  AND  REVISED  ACCORDING  TO  THE 

UNITED     STATES     PHARMACOPEIA, 

NINTH  DECENNIAL  REVISION 


ST.  LOUIS 

C.  V.  MOSBY  COMPANY 

1922 


CorYRiGHT,  1909,  1911,  1913,  1916,  1917,  by  C.  V.  Mosby  Company. 


Authority   to   use   for  comment   the  Pharmacopeia   of   the   United  States   of   America, 

Ninth  Decennial    Revision,   in   this  volume   has   been   granted   by   the  Board   of   Trustees 

of    the    United    States    Pharmacopeial    Convention,    which    Board    of  Trustees    is    in    no 

■way   responsible  for   the   accuracy    of   any  translations   of  the  official  weights   and  meas- 
ures,   or   for  any   statement   as   to   strength   of   official    preparations. 


Press  of 
C.   V.  Mosby  Company 
St.  Louis 


s 


wu 


PREFACE  TO  FIFTH  EDITION 


The  complete  exhaustion  of  the  Fourth  Edition  of  "Dental 
Materia  Medica  and  Therapeutics"  within  less  than  one  year 
after  its  publication  again  has  necessitated  a  revision  of  its  text. 
The  recently  published  Ninth  Decennial  Revision  of  the  United 
States  Pharmacopeia  contains  numerous  important  changes  rela- 
tive to  average  doses  of  drugs  and  also  the  addition  of  a  number 
of  valuable  compounds  of  special  interest  to  the  dental  practi- 
tioner. These  changes  have  been  duly  considered  in  this  present 
revision  of  the  text.  The  Avriter  is  gratified  to  know  that  the 
suggestions  which  he  made  in  his  report  as  Chairman  of  the 
Committee  of  Revision  of  the  United  States  Pharmacopeia,  Sec- 
tion of  Stomatology,  American  Medical  Association,  have  been 
found  worthy  of  consideration  by  the  general  committee  and 
have  been  duly  added  to  the  text  of  the  present  Pharmacopeia. 
These  ncAvly  added  drugs  of  special  interest  to  the  dental  prac- 
titioner are :  Cotarin  hydrochlorid,  nitrogen  monoxid,  oxygen, 
paraformaldehyd,  beta-eucain  hydrochlorid  and  sodium  per- 
borate. 

To  facilitate  the  ready  location  of  drugs  according  to  their 
therapeutic  uses  a  properly  classified  index  of  drugs  has  been 
added  so  as  to  assist  the  practitioner  in  the  quick  selection  of  a 
suitable  remedy  when  needed. 

The  article  on  Electro-Sterilization  (Ionic  Medication)  has 
been  completely  rewritten;  about  twenty  new  illustrations  have 
been  added  and  numerous  minor  changes  have  been  found  neces- 
sary so  as  to  harmonize  the  text  with  the  latest  achievements  in 
dental  materia  medica  and  therapeutics. 

H.  P. 

UNiVERsrrY  OP  Pennsylvania, 
Evans  Institute. 


PREFACE  TO  FIRST  EDITION 

A  systematic  classification  of  drugs  which  shall  answer  all  pur- 
poses has  never  been,  and  probably  never  will  be,  successfully 
arranged.  Such  a  classification  will,  according  to  the  standpoint 
from  which  the  subject  is  treated,  evince  individual  trend  of 
thought.  The  chemist,  for  example,  prefers  a  classification  ac- 
cording to  the  chemic  relationship  of  the  drugs,  the  pharma- 
cologist is  principally  interested  in  a  classification  according  to 
the  physiologic  action  of  drugs,  Avhile  the  clinician  groups  the 
drugs  according  to  their  therapeutic  effects.  The  author,  guided 
by  extensive  class-room  experience  and  clinical  practice,  has 
made  an  effort  to  point  out  how  pharmacologic  research  and 
clinical  observations  may  be  advantageously  combined  in  the 
rational  use  of  remedial  agents  for  the  purpose  of  favorably  in- 
fluencing disease.  The  entire  subject  matter  is,  therefore,  treated 
from  the  standpoint  of  the  pharmaco-therapeutist. 

The  practice  of  dentistry  requires,  in  addition  to  specific  phar- 
maceutic preparations,  quite  a  large  number  of  remedies  which 
are  seldom  employed  by  the  medical  practitioner,  unless  used  by 
him  for  totallj^  different  purposes.  These  remedies  are  gener- 
ically  termed  dental  remedies,  and  consequently  their  impor- 
tance demands  special  discussion.  To  draAv  a  definite  line  of  de- 
marcation between  dental  and  general  remedies  is  not  only  im- 
possible, but  is  distinctly  undesirable.  Frequently  conditions 
arise  where  a  knowledge  of  general  remedies  is  absolutely  neces- 
sary for  the  dental  practitioner — as,  for  example,  the  treatment 
of  certain  phases  of  pericementitis  requires  the  administration 
of  uric  acid  solvents,  specific  infection  calls  for  cathartics,  anti- 
pyretics, etc.,  and  the  mitigation  of  pain  may  necessitate  general 
anodynes. 

The  progress  of  dental  pharmaco-therapeutics  has  not  kept 
pace  with  the  remarkable  advances  made  in  the  technical 
branches  of  dentistry.  The  unsatisfactory  classification  of  dental 
remedial  agents  is  largely  due  to  a  gross  disregard  of  the  prog- 
ress made  in  general  pharmacology  and  patholog:v-.  The  prin- 
cipal part  of  operative  dentistry  is  surgery,  but  unfortunately 

6 


PREFACE  7 

the  average  practitioner  applies  the  same  iiiechaiiisiii  to  drug 
action,  and,  expecting  too  much  from  a  drug,  is  frequently 
disappointed. 

The  difficulties  which  presented  themselves  to  the  author  in 
systematizing  the  subject  Avere  the  many  conflicting  statements 
found  in  literature  relative  to  the  action  of  dental  remedies.  An 
effort  has  been  made  to  avoid  vague  information  and  to  elucidate 
only  clinical  facts  which  have  been  established  by  pharmacologic 
research.  Both  factors  are  essential  in  determining  the  true 
value  of  the  action  of  a  drug.  The  pharmaceutic  descriptions  of 
chemicals  and  drugs,  and  their  preparations  and  doses,  are  in 
conformity  with  those  given  in  the  latest  editions  of  the  Pharma- 
copeias of  the  United  States  and  Great  Britain. 

The  author  acknowledges  his  indebtedness  to  workers  in  both 
general  and  dental  pharmaco-therapeutics,  and  especially  to  the 
text  books  of  A.  Cushnj^,  R.  Kobert,  R.  Heinz,  T.  Sollmann,  and 
many  others  which  he  has  freely  consulted.  He  desires  to  thank 
his  friends.  Professor  Carl  Jung,  of  Berlin,  for  the  use  of  the 
micro-photographs  of  tooth  powder  preparations,  and  Doctors 
James  A.  Brown  and  L.  Neuhoff  for  assistance  in  the  preparation 
of  most  of  the  original  illustrations.  He  also  acknowledges  his 
obligations  to  the  S.  S.  White  Dental  Manufacturing  Company, 
Ransom  &  Randolph  Company,  Lennox  Chemical  Company, 
Gebauer  Chemical  Company,  Modern  Medical  Company,  Consoli- 
dated Dental  Manufacturing  Company,  Wm.  Mejer  Company. 
R.  S.  Squibb  &  Sons,  Burroughs  Wellcome  &  Co.,  and  Parke, 
Davis  &  Co.  for  the  use  of  various  illustrations  of  dental  appli- 
ances. 

H.  P. 

Washington  University  Dental  School, 
St.  Louis,  September,  1909. 


CONTENTS 


PART  I. 

GENERAL  THERAPEUTICS.  P^ce. 

[ntroduction       17 

The  Aim   of  Therapeutics 30 

Nature    of    Drug    Action 37 

Classification   of   Dental   Remedies 44 

Selection  of  the  Remedy 52 

Methods  of  Administering  Medicines 54 

Prescription  Writing 63 

Incompatibilities        74 

Weights  and  Measures 79 

The  Pharmacopeia  and  Pharmaceutic  Preparations 8(5 

Synopsis  of  the  National  Narcotic  (Harrison)  Law 97 

Average  Doses  of  the  Most  Important  Dental  Drugs 100 

PART  II. 
PHARMACOTHERAPEUTICS. 

Drugs  Which  Exercise  No  Definite  Action  on  Specific  Organs. 

Antiseptics        103 

Salts  of  the  Heavy  Metals,  their  Oxids,  and  their  Organic  Com- 
pounds      108 

The  Acids,  the  Alkalies,  the  Halogens  and  their  Derivatives     .  120 

Solutions  Which  Evolve  Nascent  Oxygen 134 

Antiseptics  of  the  Aromatic  Series 150 

Antiseptics  of  the  Marsh  Gas  Series 165 

Essential  Oils,  their  Derivatives,  and  their  Synthetic  Substitutes  184 

Astringents 199 

Metallic  Astringents 201 

Vegetable  Astringents 209 

Caustics 212 

Liquid    Caustics 214 

Dry    Caustics 215 

Hemostatics  and  Styptics 250 

Absorbents 251 

Caustics  and  Astringents 251 

Agents  Which  Act  After  Being  Absorbed  Into  the  Circulation  253 

Agents  Which  Act  on  the  Vessels,  but  Not  on  the  Blood     .     .  254 

0 


10  CONTENTS 

Page 

Pkotectives,  Demulcents,  and  Emollients 255 

Irritants  and  Counterirritants 260 

Antacids       268 

Drugs  Which  Act  on  Specific  Organs. 

Drugs  Wldch  Act  on  the  Mouth  and  Teeth. 

BiiEACiiiNO   Agents 270 

Preparations  for  the  Mouth  and  Teeth   (Oral  Hygiene)     ....  277 

Mouthwashes 293 

Tooth  Powders 297 

Toothpastes 306 

Tooth  Soaps 308 

Drugs  Which  Act  on  the  Peripheral  Nerves. 

Local  Anesthetics  and  Obtundents 309 

Soluble  Local  Anesthetics 312 

Insoluble  Local  Anesthetics 322 

Refrigerant   Local  Anesthetics 326 

Drugs  Which  Act  on  the  Central  Nervotis  System. 

Genkral  Anesthetics 328 

Physiologic  Action  of  Nitrous  Oxid 334 

Administration   of    Nitrous    Oxid 335 

Physiologic  Action  of  the  Anesthetics  of  the  Methan   Series     .  350 

Administration   of   Ethyl   Chlorid 353 

Preparation   of   the   Patient 358 

Choice  of  the  Anesthetic 358 

Treatment  of  Accidents  of  General   Anesthesia 359 

Hypnotics 366 

Anodynes      368 

Sedatives 374 

Cerebral   Stimulants 376 

Drugs  Which  Act  on  the  Gastro-Inteslinal  Canal. 

Stomachics  and  Digestives 379 

Emetics 383 

Cathartics 392 

Drugs  Which  Act  on  the  Circulation. 

CiRCULATOiiY  Stimulants  and  Depressants 399 

Drugs  Which  Act  on  the  Bespiration. 

Respiratory  Stimulants  and  Depressants 404 

Drugs  Which  Act  on  Metabolism. 

Tonics 406 

Alteratives 412 

Drugs  Which  Act  on  the  Secretions. 

SlALOGOGUES     AND     ANTISIALOGOGUES 419 

Diaphoretics 421 


CONTENTS  11 

Pagb 

Diuretics 42"j 

QuTC  Acid  Solvents 424 

Drugs  Which  Act  on  the  Temperature. 

Antipyretics 431 

OnCANO  AND  SiCRUM   THERAPY. 

Organo   Therapy 43(j 

Serum    Therapy 43S 

PART  111. 

PilYSlCAL   THERAPEUTICS. 

AiiTiFiciAii  Hyperemia 442 

Massage 45S 

Light   Therapy 463 

Heat    and   Cold 474 

Plugging  Bone  Cavities  with  Inert  or  Medicated  Suhstances    .    .  478 

E[,ECTIlO-STr,RH,IZA'riON     • 484 

PART  IV. 

LOCAL  ANESTHESIA. 

History 514 

Means  op  Producing  Local  Anesthesia 518 

Physiologic   Action    op    Anksthetics 519 

Local  Anesthetics 530 

Hypodermic  Armamentarium 536 

Technique  of  the   Injection 542 

Side  and  After  Effects  of  Local  Anesthetics  and  Their  Relation 

TO    THE   Penal   Code 579 

APPENDIX. 

Diagnosis  of  Diseases  of  the  Pulp  by  the  Electric  Current     .     .     .  585 

Immediate  Treatment  of  Acute  Poisoning 595 

Glossary  of  Therapeutic  Terms 599 

Diagnostic  Aids 603 

Tiiermometric  Equivalents 605 

Dose  Table 606 


ILLUSTRATIONS 

Fig.  Pace. 

1.  Office    Dropping    Bottle 50 

2.  Salt-Mouth    Bottle 50 

3.  Aseptic  Medicament  Ti'ay 51 

4.  Dental  Applicator 51 

5.  The   Miller   Pyorrhea   Pen 51 

6.  Powder  Blower •     •  56 

7.  Glaseptic    Hypodermic    Syringe 5( 

8.  Steam    Atomizer '^^ 

9.  Hand  Atomizer 59 

10.  Fac-Simile  of  a  Correctly  Written   Prescription     .......  67 

11.  Graduated  Medicine  Glass 73 

12.  Medicine    Dropper 74 

13.  Percolation 91 

14.  Infusion   Jar 92 

15.  Casserol   for  Decoctions 92 

16.  Empty  Gelatin  Capsules 93 

17.  Konseals 93 

18.  Pill   Machine 95 

19.  Suppository  Mould 95 

20.  Finished    Suppository 96 

21.  Tablet    Mould 96 

22.  Hypodermic   Tablet  Mould 97 

23.  Sample  Page  of  Record  of  Narcotic  Drugs  Dispensed 98 

24.  Culture  Plate,  with  Pack's  Cylinders  and  Abbey's  Noncohesive  Foil  110 

25.  Imaginary  Diagram  of  a  Solution  of  Mercuric  Chlorid  in  Water     .  Ill 

26.  Liquid   Soap   Dispenser 129 

27.  Minim  Syringe  for  Applying  H^O^  Solutions 138 

28.  Pyrozon    Probe    Cup 140 

29.  Oxygen  Inhalation  Apparatus 142 

30.  Portable  Oxone  Generator  (Autogenor).     Closed 143 

31.  Portable  Oxone  Generator  (Autogenor).     Opened 144 

32.  Formanganate  Disinfector,  Solution,  and  Briquettes 170 

33.  Aseptic    Absorbent    Paper    Points 180 

34.  Silver  Nitrate  Applied  to  Carious  Dentin   (low  power)        ....  220 

35.  Silver  Nitrate  Applied  to  Carious  Dentin   (high  power)      ....  221 

36.  Action  of  Silver  Nitrate  on  Dentinal  Fibrils 223 

37.  Action  of  Silver  Nitrate  on  Living  Dentin 224 

38.  Adjustable    Silver    Nitrate    Pencil 226 

39.  Action  of  Arsenic  on  the  Human  Tooth  Pulp 234 

40.  Section  of  Fig.  39,  highly  magnified 236 

41.  Necrosis  of  Pulp  after  Application  of  Arsenic 238 

13 


14  ILLUSTRATIONS 

Fig.  Page 

42.  Enlarged  Section  of  Fig.  41     .     . 239 

43.  Total  Necrosis  of  Pulp  after  Six  Days'  Arsenic  Application     .     .  241 

44.  Luxuriant   Growth   of   Penicillium   Brevicaule 240 

45.  Marsh  Apparatus  for  Detection  of  Arsenic 247 

46.  Dental  Mustard  Plasters  in  Position 20(5 

47.  "Eveready"    Mouth    Lamp 275 

48.  Zeiss  Tooth  Bleaching  Lamp 270 

49.  Electric  Heater  and  Spray  Outfit 29a 

50.  Magnified  Specinaeus  of  Tooth  Powder  Substances 299 

51.  Same   as   Fig.    50 300 

52.  Same   as   Fig.    50 301 

53.  Same   as   Fig.   50 303 

54.  Apparatus  for  Making   Nitrous  Oxid 333 

55.  Soft   Wood   Mouth   Props 336 

56.  Semi-Solid  Rubber  Bite   Blocks 336 

57.  Lawrenz   Adjustable    Mouth    Prop 337 

58.  Nitrous  Oxid  Gasometer 338 

59.  Nitrous  Oxid  Gasometer.     Sectional  view 339 

60.  Universal  Gas  Stand  for  Nitrous  Oxid 340 

61.  Surgeon's  Portable  Nitrous  Oxid  and  Oxygen  Apparatus     ....  341 

62.  S.  S.  White  Nitrous  Oxid  and  Oxygen   Apparatus 342 

63.  Coleman's   Nasal   Inhaler,   connected 343 

04.  Teter's  Combination  Gas  Stand 344 

65.  Nitrous  Oxid  Inhaler,  with  celluloid  hood 345 

66.  The  S.  S.  White  Nasal  Inhaler 346 

67.  Simplex   Inhaler.      Sectional   view 346 

68.  The  Gwathmey  Gas  Oxygen  Apparatus 347 

09.  Ethyl    Chlorid    Dropping    Tube 354 

70.  Ferguson's  Inhaler 354 

71.  Ethyl   Clilorid    Tube 355 

72.  Ermold-Stark's   Inhaler 355 

73.  McFarlane's  Ethyl  Chlorid  Inhaler 356 

74.  Gebauer's  Combination  Inhaler 357 

75.  Artificial  Respiration,  expiration 362 

76.  Artificial  Respiration,  inspiration       363 

77".  Camera  Lucida  Drawings  of  Endameba  Gingivalis 389 

78.  Photomicrograph   of  Endameba   Gingivalis 390 

79.  Composite  Outlines  of  Moving  Endameba  Gingivalis 390 

80.  Tracing  the  Blood  Pressure  under  Synthetic  Suprarenin     ....  403 

81.  Glass   Tube  for   Taking  Corrosive   Medicines     ........  408 

82.  Dunn's   Bifluorid   Syringe 429 

83.  Schematic  Drawing  of  an  Abscess 445 

84.  Suction  Cup  for  Alveolar  Abscesses  about  the  Gums 450 

85.  Suction  Cups  for  Abscesses  about  the  Cheeks,  Lips,  and  Chin     .     .  450 


ILLUSTRATIONS  15 

Fig.  Page 

86.  Application  of  the  Elastic  Bandage  for  the  Production  of  Obstruc- 

tive  Hyperemia   of   the   Head 452 

87.  Application  of  Suction  Cup  over  the  Sinus  of  an  Alveolar  Abscess     .  453 

88.  Ilyperemic  Suction  Cup  Applied  to  a  Chin  Fistula 454 

89.  Suction  Cup  Applied  to  a  Fistula  on  the  Cheek  Near  the  Border  of 

the    Mandible 455 

90.  Hyperemic    Suction   Apparatus    for    the    Treatment    of    Pyorrhea 

Alveolaris       457 

91.  Dental  Vibrator 4G1 

92.  Dental  Massage  Apparatus 462 

93.  Dental    Electric   Therapeutic    Lamp 464 

94.  Dobrzyniecki 's  Heat  and  Light  Reflector 465 

95.  Mode  of  Application  of  the  Therapeutic  Lamp 466 

96.  Electric    Thermaphone    Pad 476 

97.  Bohm's  Syringe  for  Bone  Plombe 479 

98.  Collapsible  Tube  for  Bone  Plombe 480 

99.  A  Hypodermic  Syringe  Prepared  for  Bone  Plombe 481 

100.  A  Large  Cavity  in  the  Mandible  Filled  with  Bone  Plombe     .     .     .  482 

101.  Manifestations    of    Bismuth    Poisoning    in    the    Mouth    Following 

Bismuth  Paste    Injection .  483 

102.  Scheme    Showing   the    Movement    of   Ions 490 

103.  Experiment   Showing  Passage   of   Ions 492 

104.  The  S.  S.  White  Current  Controller 498 

105.  Weston  Milliamperemeter 498 

106.  Metal    Negative    Hand    Electrode 499 

107.  Sponge    Negative    Hand    Electrode 500 

108.  Sponge   Wrist    Electrode 500 

109.  Long  Handle  Electrode  With  Iridio-Platinum   Point 501 

110.  Insulated  Electrode  Holder 501 

111.  Galvanic  Battery  for  Electro-Sterilization 502 

112.  Switchboard     for     Electro-Sterilization 503 

113.  Switchboard     for     Electro-Sterilization 504 

114.  Lower   Right   Second   Bicuspid 508 

115.  Same  Tooth  as  in  Fig.  114,  after  treatment 508 

116.  Upper  Left   First   Bicuspid 508 

117.  Same  Tooth  as  in  Fig.  116,  after  treatment 50S-, 

118.  Plasmolysis  of  Cells  of  Tradescantia  Discolor 520 

119.  Diagrams  Showing  the  Effect  Upon  Human  Red  Blood  Corpuscles 

of  (A)  Isotonic,  (B)  Hypotonic,  and   (C)  Hypertonic  Solutions  522 

120.  Contraction  of  the  Heart  of  a  Frog 523 

121.  Ethyl   Chlorid   Spray  Tube    (Glass) 525 

122.  Ethyl  Chlorid  Spray  Tube    (Metal) 526 

123.  Application  of   the   Ethyl   Chlorid    Spray 527 

124.  Large  and  Small  Porcelain  Dissolving  Cups  for  Preparing  Sterile 

Novocain    Solution 533 

125.  Dropping  Bottle 534 


16  ILLUSTRATIONS 

Fig.  Pagb. 

12G.     Glass   Measure   For    Local   Anesthetics 534 

127.  Hermetically  Sealed  Glass  Ampuls  of  Various  Types 535 

128.  Novocain   Armamentarium 536 

129.  The  S.  S.  White  Aseptic  All-Glass  Syringe 537 

130.  Thoma  Sterilizer  for  Hypodermic  Syringes,  Dissolving  Cups,  etc.  538 

131.  All-Metal  Syringe  and  Curved  Needle  Attachment 539 

132.  Dental  Hypodermic  Needles 540 

133.  H}-podermic  Needles  of  Various  Designs  for  Dental  Purposes     .  540 

134.  Needle  Attachments  for  Parke,  Davis  &  Co.'s  Sj'ringe     ....  541 

135.  Cross   Section   of  a   Right   Lower   Jaw 544 

136.  Horizontal  Section  Through  the  Alveolar  Process  of  the  Lower  Jaw  545 

137.  The  Nerve  Supply  of  the  Upper  and  Lower  Jaw 546 

138.  The  Nerve  and  Blood  Supply  of  the  Hard  Palate 547 

139.  Subperiosteal  Injection 548 

140.  Direction  of  Needle  in  the  Subperiosteal  Injection  About  a  Canine  549 

141.  Subperiosteal  Injection  About  an  Upper  Molar 550 

142.  Peridental  Injection  about  a  Bicuspid 551 

143.  A,    Subperiosteal    Injection;    B,   Peridental    Injection;    C,    Intra- 

osseous Injection  about  a  Canine 552 

144.  Perineuria!  Injection  about  the  Foramen  of  Scarpa  and  about  the 

Posterior  Palatine  Canal 554 

145.  Mandibular    Sulcus 555 

146.  Eelation  of  Nerve  and  Vessels  in  the  Pterygomandibular  Space     .  556 

147.  Horizontal  Section  of  a  Frozen  Head  made  1  cm.  above  the  Oc- 

clusal Surfaces  of  the  Teeth  of  the  Lower  Jaw 558 

148.  Injection   into   the   Mandibular   Foramen 559 

149.  Seidel's    Technique 560 

150.  An  Abnormal  Course  of  the  Mandibular  Canal 561 

151.  Perineurial   Injection   About   the   Infra-orbital   Foramen    and    the 

Alveolar  Foramina 562 

152.  Loeffler's  Pressure  Syringe  Attachment  For  Anesthetizing  the  Pulp  565 

153.  An   Aqueous   Solution   of   Eosin   Forced   Through   Dentin   With   a 

Jewett-Wilcox   Syringe 566 

154.  Section  Through  the  Root  of  a  Molar 568 

155.  Points  for  Pressure  Obtunding  Syringe 569 

156.  Weaver    High    Pressure    Obtunding    Syringe 571 

157.  Anesthetizing  a  Small  Tumor  by  Rhomboid  Injection 577 

158.  Section  Through  an  Anesthetized   Tumor 578 

159.  Typical  Small  Faradic  Battery,  with  Induction  Coil  and  Core  Shield  586 

160.  Dental   Electrode 587 

161.  Dental   Hard   Rubber   Electrode   with  Interrupter 587 


PART  I 
GENERAL  THERAPEUTICS 


INTRODUCTION 

The  practice  of  medicine  is  as  old  as  the  human  race.  How- 
ever crude  the  efforts  may  have  been,  we  are  justified  in  believ- 
ing that  men  have  tried  from  the  earliest  times  to  render  assist- 
ance to  their  fellowmen  in  ease  of  illness.  Most  likely  these  first 
attempts  were  principally  of  a  surgical  nature,  and  only  later  in- 
ternal diseases  received  attention.  In  due  time  the  natural  in- 
stinct inherent  in  both  man  and  beast  led  to  the  utilization  of  the 
products  of  their  immediate  surroundings — primarily  of  herbs  and 
plants,  and  later  of  animal  drugs.  It  became  a  part  of  the  sym- 
pathetic duties  of  woman  to  look  after  the  ills  of  the  family.  Close 
observation  and  practice  enlarged  the  circle  of  medical  vision,  and 
"the  wise  woman  of  the  clan"  originated,  of  whom  we  find  even 
today  isolated  specimens.  With  the  progress  of  civilization  and 
the  entering  of  religion  into  the  routine  duties  of  the  daily  life, 
diseases  were  mostly  regarded  as  punishments  from  the  gods,  and 
it  was  left  to  the  priests  to  care  for  both  the  spiritual  and  the 
bodily  welfare  of  their  community.  Among  the  less  cultured  the 
curing  of  diseases  consisted  in  administering  mysterious  concoc- 
tions, accompanied  by  the  claptrap  of  the  conjuror,  a  remnant  of 
which  we  find  in  the  present  practice  of  the  medicine  man  of  the 
aborigines.  With  the  evolution  of  the  races  the  practice  of  se- 
lecting suitable  remedies  for  certain  diseases  became  a  matter  of 
systematic  observation  and  study.  Instinctive  empiricism  selected 
a  number  of  remedies  which  were  especially  suited  for  its  pur- 
poses— those  which  were  used  to  remove  certain  dangerous  symp- 
toms, or  to  bring  about  and  strengthen  other  symptoms  which  ap- 
parently had  a  beneficial  influence  upon  the  disease.  Irritants  and 
counterirritants  applied  externally  and,  to  a  limited  extent,  inter- 
nally were  probably  the  first  therapeutic  attempts  at  influencing 

17 


18  GENERAL   THERAPEUTICS 

diseased  conditions.  They  were  followed  by  those  remedies  which 
mitigate  irritation  and  allay  inflammation,  and  finally  by  those 
which  alleviate  pain.  Popular  medicine  is  the  foundation  of  the 
scientific  therapeutics  of  all  nations.  Naturally,  the  remedial 
agents  differ  with  each  nation.  Systematic  search  for  new  rem- 
edies was  introduced  much  later  as  a  result  of  close  observation 
of  the  action  of  certain  drugs. 

For  example,  the  bark  of  various  species  of  cinchona,  a  native  tree  of 
Western  South  America,  is  an  old  and  trusted  remedy  in  certain  specific 
febrile  diseases,  especially  malaria.  The  Indians  of  Peru,  Bolivia,  etc.,  used 
it  for  such  purposes  prior  to  the  invasion  of  their  country  by  the  Spaniards 
in  1604.  The  vicereine  of  Peru,  Countess  Ana  of  Cliinchon,  was  cured  of 
an  attack  of  malaria  by  this  drug  in  1638,  and  in  her  honor  Linnaeus  in  1740 
named  the  plant  chinchona.  Someone  blundered  in  the  original  spelling  of 
"chinchona"  and  ever  since  it  has  been  written  cinchona.  Countess  Ana 
collected  large  quantities  of  the  powdered  bark  and  distributed  it  among 
her  people  ill  with  "tertiana,"  a  form  of  malaria.  The  powder  became 
known  as  "Pulvo  de  la  Condesa. "  At  the  beginning  of  the  seventeeth  cen- 
tury it  was  introduced  into  Spain  through  the  activities  of  the  Jesuit  Fatliers 
and  it  was  then  and  is  even  today  familiarly  referred  to  as  "Jesuit  or 
Countess  Powder  or  Bark"  or  simply  as  "Bark."  An  English  nobleman  by 
the  name  of  Talbot  or  Talber  established  quite  a  trade  in  France  by  selling 
the  powder  as  a  secret  preparation  under  the  name  of  Febrifugum  Anglicum. 
He  was  fortunate  enough,  in  1682,  to  cure  the  Dauphin  of  France  of  a  case 
of  ague  and  Louis  XIV  was  so  very  much  delighted  with  Talbot's  services 
that  he  paid  him  a  truly  "royal"  fee  for  divulging  his  secret.  The  King 
ordered  the  publication  of  the  secret  and  'quinquina,"  as  the  remedy  was 
known  in  France  during  the  seventeentli  and  eighteenth  centuries,  soon  be- 
came the  world  famous  panacea  for  the  cure  of  malarial  fever. 

The  alkaloid  quinin  was  discovered  by  Pelletier  and  Caventou  in  1820. 
Its  pharmacologic  action  on  the  blood  was  observed  by  Binz  in  1869.  Finally, 
in  1880,  Laveran  discovered  the  causative  factor  of  malaria,  the  Plasmodium 
malariae,  in  the  human  blood,  and  scientists  were  now  able  to  demonstrate 
the  microbicidal  effects  of  quinin  when  it  was  brought  in  contact  with  blood 
which  contained  this  parasite. 

Again,  the  use  of  oil  of  cloves  employed  as  a  toothache  remedy  is  of  an 
old  and  unknown  origin.  Its  pharmacologic  action  depends  on  the  pres- 
ence of  eugenol,  an  unsaturated  aromatic  phenol.  Pure  oil  of  cloves  as  well 
as  eugenol  are  slightly  caustic.  To  overcome  this  defect  benzoyl-eugenol  and 
cinnamyl-eugenol  were  prepared.  Both  compounds,  however,  possess  little 
therapeutic  eflSciency.  The  basic  constituent  of  eugenol  consists  of  para- 
amido-benzoic  acid,  a  body  which  as  such  does  not  exhibit  any  therapeutic 
effects.  Its  methylester,  anesthcsin,  is  an  efficient  local  anesthetic;  how- 
ever, it  is  only  slightly  soluble  in  water.  Einhorn  and  Uhlfelder,  taking 
anesthesin  as  a  base  for  their  synthetic  research  produced  in  due  time  some 


INTRODUCTION  1 9 

four  hundred  odd  combinations  and  finally  succeeded  in  preparing  para- 
amido-benzoyl-diethly-amino-ethanol,  commercially  known  as  novocain,  which 
at  present  is  the  most  efficient  substitute  for  cocain. 

And  ipecacuanha,  which  has  been  recently  introduced  by  Smith  and  Bar- 
rett in  the  form  of  its  alkaloidal  salt,  emetin  hydrochlorid,  as  a  curative 
agent  in  the  treatment  of  pyorrhea  alveolaris,  has  had  within  the  last  four 
centuries  a  most  interesting  career.  Ipecacuanha,  also  written  "  hypecacuana  " 
by  the  practitioners  of  bygone  days — or  known  as  poaya  by  the  Brazilians— 
and  commonly  referred  to  as  ipecac,  is  the  dried  root  of  what  is  commercially 
known  as  Rio,  Brazilian,  and  Para,  or  as  Carthagena  ipecac.  The  name 
ipecacuanha  seems  to  be  of  Indian  origin,  and  may  be  interpreted  as  "vom- 
iting-producing weed."  It  is  a  native  of  South  America  and  was  intro- 
duced in  Europe  at  about  1617.  From  an  historic  point  of  view,  ipecac  is 
first  mentioned  in  literature  by  a  Portuguese  friar  who  it  seems  had  re- 
sided in  Brazil  from  about  1570  to  1600.  He  mentions  three  remedies  for 
the  "bloody  flux,"  one  of  which  is  called  igpecaya  or  pigaya.  The  drug 
here  referred  to  is  undoubtedly  ipecac.  Piso  and  Marcgraf,  in  their  scien- 
tific exploration  of  Brazil,  record  the  plant  ipecacuanha,  which  they  depicted, 
and  they  also  described  its  medicinal  properties.  As  stated  above,  it  was 
introduced  in  Europe  in  1617.  Although  well  known  from  the  accounts  given 
by  Piso  and  Marcgraf,  and  in  common  use  in  Brazil  as  a  remedy  in  dysentery, 
ipecac  was  not  employed  in  Europe  prior  to  the  year  1672.  At  that  time 
a  physician  named  LeGras  brought  from  South  America  a  quantity  of  the 
root  to  Paris,  but  administering  it  in  too  large  doses  he  damaged  rather  than 
aided  the  reputation  of  this  drug. 

A  few  years  later  a  merchant  of  Paris  named  Grenier  or  Garnier  became 
possessor  of  150  pounds  of  ipecac,  the  valuable  properties  of  which  in  dys- 
entery he  vaunted  to  his  medical  attendant  Aiforty  and  to  Jean  Claude  Adrien 
Helvetius,  a  pupil  of  the  latter.  Grenier  presented  a  quantity  of  this  new 
drug  to  Afforty,  who,  however,  attached  but  little  importance  to  it.  Hel- 
vetius, on  the  other  hand,  was  induced  to  prescribe  it  in  cases  of  dysentery, 
which  he  did  with  the  utmost  success.  He  even  caused  placards  to  be  af- 
fixed to  the  corners  of  the  streets  (one  of  which  may  still  be  seen  in  Paris) 
announcing  his  successful  treatment  with  this  new  drug.  Through  Grenier 
he  obtained  ample  supplies  from  Spain  and  sold  it  as  a  secret  medicine.  The 
fame  of  the  cures  effected  with  this  drug  by  Helvetius  reached  the  French 
court  and  caused  some  trial  to  be  made  at  the  Hotel  Dieu.  These  trials 
having  been  fully  successful,  Louis  XIV  accorded  to  Helvetius  the  sole  right 
of  vending  his  remedy.  Subsequently,  several  well-known  personages,  in- 
cluding the  Dauphin  of  France,  experienced  the  beneficial  action  of  this  drug 
upon  their  own  bodies.  The  King  became  again  interested  in  this  drug,  and 
consulted  with  his  physician,  D'Aquin,  and  his  father  confessor,  and  through 
them  negotiated  the  purchase  from  Helvetius  of  his  secret  for  a  thousand 
louis  d'or,  and  made  it  public.  The  right  of  Helvetius  to  this  payment  was 
disputed  in  law  by  Grenier,  but  maintained  by  a  decision  of  the  Chatelet  of 
Paris. 

In   1696  ipecac  was  introduced   into  Germany  by  the  renowned  philosopher 


20  GENERAL   THERAPEUTICS 

Leibnitz,  who  by  its  use  had  been  cured  of  a  severe  case  of  dysentery.  It  be- 
came known  in  German  literature  as  "Euhrwurzel"  (dysentery  root),  and 
only  much  later  its  name  changed  to  "  Brechwurzel "  (vomiting-producing 
root).  The  first  title  seems  to  have  been  in  general  favor  with  medical 
writers  of  that  period,  as  in  the  older  works  on  materia  medica  ipecac  is  fre- 
quently referred  to  as  radix  antidysentaria,  indicating  its  therapeutic  appli- 
cation. Prior  to  the  beginning  of  the  nineteenth  century  ipecac  was  not  em- 
ployed to  any  extent  as  an  emetic;  its  greatest  virtues  were  extolled  in  the 
treatment  of  the  various  forms  of  dysentery  and  "bloody  flux,"  as  it  was 
known,  and  in  similar  disturbances  of  the  intestinal  canal.  It  is  stated  that 
during  an  endemic  outbreak  of  dysentery  in  Nimeguen  (Holland)  in  1727 
many  thousands  of  soldiers  became  afflicted  with  this  serious  malady.  The 
army  surgeons  administered  ipecac  empirically  as  a  specific,  and  Geoffrey's 
report  tells  us  that  "in  one  day  whole  companies  of  soldiers  afflicted  with  this 
most  distressing  ailment  were  cured  by  ipecacuanha  like  magic." 

Ipecac,  in  conjunction  with  opium,  forms  the  principal  component  of  the 
world-famous  Dover's  powder,  and  both  diugs  share  equal  rights  in  the  ther- 
apeutic fame  of  this  galenic  preparation.  The  inventor  of  this  widely  used 
remedy,  Thomas  Dover,  was  born  in  Barton-on-the-Heath,  England,  in  1660. 
He  studied  under  the  renowned  Thomas  Sydenham  and  obtained  his  medical 
degree  at  Cambridge  in  1687.  In  1708  he  fitted  out  an  expedition  to  the 
South  Seas,  accompanying  the  ship's  crew  as  their  surgeon.  It  is  stated  that 
in  1709  he  discovered  a  sailor  by  the  name  of  Alexander  Selkirk,  marooned 
for  four  years  on  Juan  Fernandez  Island.  Selkirk  returned  with  Dover  to 
England,  and  it  is  supposed  that  he  is  the  original  of  Daniel  Defoe's  Rob- 
inson Crusoe.  Dover  finally  settled  in  England  and  assumed  the  practice  of 
medicine  in  Bristol  in  1711.  In  1762  was  published  his  famous  work  "An- 
cient Physician's  Legacy  to  His  Country,"  which  among  many  other  in- 
teresting material  contains  the  formula  of  his  diaphoretic  powder. 

In  1875  Loesch  found  amebas  in  the  stools  of  dysenteric  patients,  but  did 
not  regard  them  as  a  cause  of  the  disease.  Finally,  in  1896,  Kartulis  ap- 
parently settled  the  question  by  stating  that  dysentery  and  tropical  liver 
abscess  associated  with  dysentery  were  caused  by  the  presence  of  the  ameba 
coli. 

"While  ipecac  has  been  lauded  again  and  again  in  the  treatment  of  this 
disease,  especially  in  more  modern  times  by  Dock,  Manson,  and  others,  it  was 
left  to  Vedder  to  show  that  emetin  would  kill  the  endameba  in  vitro.  The 
chain  of  evidence  was  finally  closed  by  Rogers,  in  1912,  when  he  demon- 
strated the  specific  nature  of  emetin  in  patients  suffering  from  endamebic 
dysentery. 

When  we  realize  that  ever  since  Riggs  of  Hartford,  in  1867,  called  espe 
cial  attention  to  the  treatment  of  pyorrhea  alveolaris,  which  since  has  been 
christened  Riggs'  disease,  the  greater  majority  of  those  drugs  which  generic- 
ally  are  classified  as  antiseptics,  caustics,  and  astringents — and  incidentally 
not  a  few  other  drugs  which  in  reality  have  no  bearing  whatsoever  on  the 
subject — have  been  recommended  at  one  time  or  another  by  that  vague  and 
humorous  phrase,  "It  is  of  value  in  the  treatment  of  pyorrhea,"  the  intro- 


INTRODUCTION  21 

duction  of  emetin  as  a  remedial  agent  for  such  purposes  must  be  heralded  as 
an  epoch-making  step  in  pathology  and  therapeutics.  The  discovery  of  en- 
damebas  in  pyorrheal  pus,  and  the  subsequent  treatment  of  this  disease 
with  emetin,  as  recorded  by  Smith  and  Barret,  and  independently  verified 
by  Bass  and  Johns,  and  by  many  other  observers,  is  an  attainment  of  pa- 
tient scientific  investigation  which  is  deserving  of  the  unrestricted  praise 
of  the  dental  and  medical  professions  the  world  over. 

The  early  history  of  dental  medicine  is  so  closely  interwoven 
with  that  of  medical  therapeutics  that  it  is  impossible  to  distin- 
guish it  from  its  mother  science.  The  Babylonians,  Egyptians, 
Assyrians,  Hebrews,  Hindus,  Greeks,  and  Romans  were  the  early 
cultured  inhabitants  of  whom  historical  records  exist.  The  re- 
cent excavations  in  Babylon  have  brought  to  light  some  interest- 
ing facts  concerning  the  practice  of  dentistry  under  King  Ham- 
murabi, at  about  2250  b.  c.  The  law  stated  that  "if  one  knocks 
out  a  tooth  of  one  of  his  caste,  his  own  tooth  shall  be  knocked 
out,  while,  if  it  is  the  tooth  of  a  freeman,  he  pays  one-half  mine 
silver."  The  Egyptian  medical  history  is  principally  recorded 
in  the  various  papyri,  especially  those  of  Ebers  and  of  Brugsch, 
which  probably  cover  the  period  of  3700  to  1500  B.C.  The  Egyp- 
tian physicians  were  largely  specialists,  and  it  is  very  probable 
that  some  were  selected  to  look  after  the  welfare  of  the  teeth. 
Most  of  the  dental  remedies  found  in  the  papyri  consist  of  pastes, 
powders,  plasters,  decoctions,  etc.,  in  which  St.  John's  bread,  sage 
seed,  honey,  and  some  unknown  plants  play  important  parts. 
The  treating  of  abscesses,  caries,  and  loose  teeth  seems  to  have 
been  known.  The  Hindus  were  apparently  very  proud  of  their 
teeth.  It  is  recorded  that  the  use  of  tooth  powders  and  washes, 
and  especially  the  use  of  the  tooth  cleaner,  "rinacarya,"  were 
necessities  of  their  daily  toilet.  As  a  toothpick  they  employed  a 
bitter  tasting  wood,  which  when  chewed,  produced  a  fibrous  bun- 
dle, which  was  then  used  as  a  brush  for  the  gums  and  the  teeth. 
The  aborigines  of  the  western  coast  of  Africa  are  still  using  the 
wood  of  the  sissako  and  the  molungo  tree  for  such  purposes  and 
a  toothbrush  of  this  very  same  nature  has  been  recently  intro- 
duced in  the  United  States,  in  Great  Britain,  and  in  Russia.  In 
the  writings  of  Hippocrates  and  Pliny  frequent  allusion  is  made 
to  drugs  which  were  especially  advocated  for  diseases  of  the  teeth 
and  the  mouth.  With  the  simpler  remedies— as  hyssop,  licorice, 
dog's  milk,  goat's  butter,  etc. — many  disagreeable  substances,  espe- 


22  GENERAL   THERAPEUTICS 

cially  of  the  animal  kingdom,  were  recommended.  In  Pliny's  writ- 
ings wc  find,  among  other  dental  suggestions,  that  "if  one  wishes 
to  be  free  from  toothache,  one  should  eat  a  whole  mouse  twice  a 
month. ' ' 

The  ancient  writings  on  dental  therapeutics  contain  so  many 
conflicting  statements  relative  to  the  sources  of  specific  medications 
that  it  is  extremely  difficult  to  reach  an  unbiased  decision  regard- 
ing their  origin.  Plagiarism  was  of  common  occurrence  among 
the  early  scribes ;  it  was,  however,  not  looked  upon  as  a  breach  of 
literary  etiquette  in  the  same  sense  of  the  word  as  we  interpret 
this  term  today.  As  an  illustration  we  may  be  permitted  to  cite 
Pliny  (79  a.d.),  who  in  his  famous  "Naturalis  Historia"  prides 
himself  on  the  fact  that  he  is  able  to  present  excerpts  of  nearly 
one  hundred  writers  and  their  two  thousand  works.  He  is  honest 
enough,  however,  to  name  these  authors,  while  many  of  his  col- 
leagues of  this  and  a  later  period  prefer  silence  on  this  point. 
Even  the  renowned  Galen  (131-200  a.d.)  oavcs  most  of  his  botani- 
cal knowledge  as  presented  in  "De  simplicium  medicamentorum " 
to  the  materia  medica  of  Dioscorides,  which  he  duly  acknowledges. 
Again,  the  seven  books  of  Paulus  ^gineta  (about  600  a.d.)  are 
primarily  compilations  culled  from  Galen  and  Oribasius  (about 
360  A.D.). 

The  dental  therapeutics  as  presented  by  the  more  important 
Greco-Koman  writers — Galen,  Oribasius,  Celsus,  Aurelianus,  Paulus 
.^gineta,  etc. ;  the  Arabo-Persians — Ehazes,  Ali  Abbas,  Abulcasis, 
Avicenna,  and  Mesue ;  the  early  Germans — Schenck  von  Grafenberg, 
Heinrich  von  Pfolsprundt,  and  Ryff;  the  early  Italians — Arcu- 
lanus  and  Vigo;  and  the  early  French — Guy  de  Chauliac,  Vales- 
cus.  Pare  and  Houillier; — all,  in  their  final  analysis,  are  culled 
from  Dioscorides.  Especially  Avicenna  (980-1037),  "the  prince 
of  Arabian  physicians,"  as  he  has  been  styled,  and  whose  treatise 
on  general  medicine — the  "Canon"— for  many  centuries  enjoyed 
equally  as  high  a  reputation  as  did  the  works  of  Galen,  and  today 
is  still  to  be  found  in  many  homes  of  Asiatic  Turkej'',  has  been  a 
flagrant  plagiarist  of  Dioscorides'  dental  medicine.  And  "Walther 
II.  Ryff  (1500-1572),  that  "jaek-of-all-trades"  to  whom  Haeser 
refers  as  "the  roving  plagiator,"  compiled  his  dental  medicine 
from  the  same  source  via  Arculauus.  The  dental  remedies  re- 
ferred to  by  that  mixture  of  charlatanism  and  necromancy,  John 


INTRODUCTION  23 

Gaddesden  (about  1310  a.d.),  sometime  professor  in  Merton  Col- 
lege, Oxford,  are  so  thoroughly  tainted  by  medical  avarice,  super- 
stition, and  ignorance  that  it  would  be  an  insult  to  the  enumerated 
writers  if  we  place  him  in  the  same  category.  Merely  to  men- 
tion a  typical  example  of  the  disgusting  therapeutic  measures  re- 
corded in  his  bizarre  tome,  "Rosa  medicinge,"  which  has  been  sig- 
nificantly dubbed  by  the  illustrious  Guy  de  Chauliac, ' '  Rosa  f atua, ' ' 
the  following  "mixtum  compositum"  in  the  form  of  a  decoction 
which  he  recommended  to  be  taken  against  dental  podagra  (neu- 
ralgia), may  be  cited:  The  gall  of  a  cow,  wormwood,  alum,  pep- 
per, nutgalls,  cloves,  pitch,  mustard  seed,  the  heart  of  a  magpie, 
the  fat  of  mice,  crow-dung,  plantain,  and  lice. 

The  famous  German  "Artzney  Buchlein  wider  allerlei  Kranck- 
heit  und  Gebrechen  der  Zeen  gezogen  aus  dem  Galeno,  Avicenna, 
Mesne,  Cornelio  Celso,"  etc.,  Leipsic,  1530,  is  an  ananymous  com- 
pilation which,  as  far  as  its  pharmaco-therapeutics  is  concerned, 
merely  exhibits  the  same  stigmata  as  do  the  works  of  the  above 
mentioned  writers,  i.e.,  it  is  an  epitome  from  Dioscorides'  disserta- 
tions, with  slight  alterations,  as  a  sequence  of  having  passed  through 
the  works  of  the  various  authors  enumerated  on  its  title-page. 

In  a  most  interesting  collection  of  Anglo-Saxon  manuscripts  bear- 
ing the  quaint  title,  "Leechdoms,  Wortcunning  and  Starcraft," — 
which  in  modern  English  would  signify  "Physicians'  Prescrip- 
tions, the  Knowledge  of  Plants,  and  Astrology,"  and  which  was 
published  some  decade  ago  in  London — numerous  references  re- 
lating to  the  diseases  of  the  teeth  are  contained.  Here,  again, 
one  meets  with  many  drugs  which  are  readily  traced  to  a  dis- 
semination of  dental  knowledge  by  the  Greco-Roman  military  sur- 
geons accompanying  the  conquering  cohorts  during  their  occupa- 
tion of  Britain. 

It  is  probably  not  amiss  to  depict  at  this  moment  a  conception 
of  the  practice  of  medicine,  and  incidentally  of  dentistry,  as  one 
may  gather  it  from  the  study  of  the  medical  works  written  dur- 
ing the  early  centuries  of  the  Christian  era.  The  frceborn  Roman 
looked  upon  the  practice  of  medicine  as  a  handicraft,  the  pursuit 
of  which  was  not  compatible  with  the  dignity  of  a  "civis  Ro- 
manus."  The  practice  of  medicine  in  Rome  prior  to  its  invasion 
by  the  better  educated  Greek  physicians  was  carried  on  by  slaves; 
the  larger  estates  depended  on  their  "servus  medicus,"  a  slave 
who  liad  acquired  some  routine  medical  knowledge,  or  the  ills  of 


24  GENERAL   THERAPEUTICS 

the  subjects  of  the  household  Avere  looked  after  by  the  patriarchal 
"pater  familias."  Some  of  these  latter  representatives  of  lay 
medicine  gathered  together  quite  an  extensive  knowledge  of  the 
healing  art,  and  their  recorded  experiences  furnish  some  of  the 
most  valuable  data  to  the  medical  historians.  Celsus,  Pliny,  and 
Cato  are  elucidative  types  of  Roman  lay  practitioners,  and  inci- 
dentally are  voluminous  and  fruitful  litterateurs  on  this  subject. 
To  the  cultured  Romans,  who  were  highly  conscious  of  the  bless- 
ings of  personal  hygiene,  the  demand  for  the  services  of  some 
genius  who  would  keep  their  masticating  organs  in  perfect  condi- 
tion was  a  matter  of  necessity.  The  works  of  medical  writers  of 
this  period  are  filled  with  innumerable  recipes  for  tooth  prepara- 
tions. The  mechanical  side  of  dentistry,  which  by  necessity  must 
have  been  carried  out  by  specialists,  has  received  its  ample  share, 
as  is  testified  by  an  excerpt  from  the  famous  Law  of  the  XII 
Tables,  enacted  450  b.c,  which  contains  the  following  paragraph: 
"Neither  add  any  gold  (to  a  corpse),  but  if  anyone  shall  have 
teeth  bound  with  gold,  it  shall  be  no  offense  to  bury  or  burn  him 
with  it."  Numerous  specimens  of  Roman  and  Etruscan  dentistry 
have  been  found  in  burial-places.  The  gi-eat  satirist,  Martial,  has 
preserved  the  name  of  at  least  one  dentist,  Cancellius,  "who  has 
grown  rich  like  a  senator  among  the  grands  and  belles  dames,  and 
who  cures  the  tooth  diseases;  and  how  he  can  extract!"  It  is 
also  of  interest  to  note  that  in  the  epigrams  of  Martial  many  al- 
lusions are  made  to  the  teeth  and  their  care.  So  we  read,  for 
instance : 

Esse  quid  hoc  dicam,  quod  dent  Uia  basia  myrrham? 
How  do  I  explain  it  that  your  kiss  smells  of  myrrh  f 

Myrrh,  which  was  brought  from  Asia  Minor  and  Egypt,  seems 
to  have  been  quite  a  favorite  mouth  preparation  with  the  Roman 
ladies.  Aside  from  its  use  as  a  mouth  wash,  it  was  also  applied 
in  combination  with  other  fragrant  gums  as  mouth  pastilles 
(cachous)  : 

Ne  gravis  hesterno  fragres,  Frescennia,  vitw 

Pastillas  Cosmi,  luxuriosa,  voras. 

That  the  breath  of  your  mouth  may  not  smell  from  yesterday's  wine^ 

Frescennia,  you  use  Cosmus'  mouth  pastilles. 

Artificial  teeth  seem  to  have  been  quite  fashionable  with  the 
Roman  dames,  as  the  following  would  indicate: 


INTRODUCTION  25 

Dentibus  atque  comis,  nee  te  pudet,  uteris  emtis; 

Quid   fades   oculo,   Laelia?     Non    emitur. 

Without  shame  you  make  show  with  bought  teeth  and  hair; 

But  what  about  the  eye,  Laelia;  can  one  buy  this  also? 

Specimens  of  Etruscan  dentistry  in  the  form  of  bridges,  crowns, 
bands,  etc.,  are  still  preserved  in  the  National  Museum  of  Naples. 

With  the  exception  of  a  few  monographs  the  early  literature  of 
dentistry  is  found  scattered  among  the  various  treatises  on  gen- 
eral midicine.  In  the  large  majority  of  instances  these  records 
are  published  by  medical  practitioners,  although  sometimes  by  lay- 
men who  themselves  did  not  practice  the  art  of  dentistry.  Prior 
to  the  appearance  of  the  work  of  Fauchard,  "Le  Chirurgien  Den- 
tiste"  (1728),  who  has  been  significantly  styled  the  ''Restaurateur 
de  la  chirurgie  dentaire, "  dentistry  is  not  entitled  to  the  cognomen 
of  a  ''learned  profession."  In  reality  it  constituted  the  handi- 
craft of  vagabonds  who  traversed  the  country  from  one  end  to  the 
other  practicing  medicine,  dentistry,  alchemy,  chiromancy,  and 
necromancy  as  occasion  demanded,  now  and  again  interspersing 
these  with  a  little  pilfering.  The  professional  mountebank  who 
presented  himself  as  a  tooth-puller,  barber,  leech,  and  theriac  ven- 
der was  a  familiar  figure  in  the  market-places  of  the  big  cities  or 
at  the  annual  fairs  of  the  smaller  towns.  The  extraction  of  the 
aching  tooth  was  incidentally  an  incentive  for  the  sale  of  some 
tooth  preparation  or  an  amulet  for  the  prevention  of  the  occur- 
rence of  pain  in  the  remaining  teeth.  The  ' '  dentatores  "  or  "  den- 
tispices"  of  the  Romans,  the  "cavadenti"  of  the  Italians,  the  "ar- 
racheur  des  dents"  of  the  French,  the  "zahnbrecher"  of  the  Ger- 
mans, and  the  "kindhart"  of  the  English  represented  the  bulk  of 
our  professional  ancestors.  Henry  Chatlee  of  London  published  an 
interesting  volume  in  1539,  in  which  he  describes  this  latter  itin- 
erant tooth-drawer.  Usually  he  was  rigged  up  in  a  fantastic  cos- 
tume, wearing  a  cap  on  which  he  displayed  conspicuously  a  large 
leaden  brooch,  being  an  effigy  of  St.  George,  which  was  commonly 
regarded  as  one  of  his  peculiarities.  To  signify  his  profession  he 
had  his  belt  garnished  with  a  string  of  extracted  teeth.  Chattlee 
defines  this  professional  charlatan  in  the  following  way:  "Gentle- 
men and  good  fellows,  whose  kindness  having  christened  me  with 
the  name  of  Kindhart  binds  me  in  all  kind  course  I  can  to  de- 
serve the  continuance  of  your  love:  Let  it  not  seem  strange,  I 
beseech  ye,  that  he  that  all  the  days  of  his  life  hath  been  famous 


26  GENERAL   THERAPEUTICS 

for  drawing  teeth  should  now  in  drooping  age  hazard  contempt- 
ible infamy  by  drawing  himself  into  print."  The  keen-pointed 
pencil  of  the  satirist  Hogarth  has  left  us  a  barber's  sign  displayed 
in  that  famous  thoroughfare  Charing  Cross  (about  1740),  with 
this  legend:  "Shaving,  bleeding,  and  teeth  drawn  with  a  touch. 
Ecce  signum!"  In  Paris,  during  the  sixteenth  to  the  eighteenth 
centuries,  the  ''Pont-Neuf"  was  the  common  meeting-ground  for 
establishing  the  "theatre  ordinaire  de  ces  imposteurs, "  as  Fauch- 
ard  ironically  refers  to  it;  and  at  least  one  of  these  "arracheurs 
des  dents,"  LeGrand  Thomas,  as  he  styled  himself,  succeeded  in 
being  counted  among  the  "Immortels." 

Among  the  ancient  writings  on  dental  medicine  a  most  interest- 
ing record  is  available  which  furnishes  a  complete  and  luminous 
description  of  the  then  existing  state  of  dental  therapeutics,  and 
which  is  not  duplicated  in  any  other  work  known  to  the  writer. 
The  book  is  entitled  "The  Home  Remedies  of  Pedanios  Dioscoridcs. " 
It  comprises  the  pharmaco-therapeutics  of  the  then  known  dis- 
eases, such  as  headaches,  diseases  of  the  eyes  and  the  ears,  the 
teeth  and  the  gums,  the  other  diseases  of  the  mouth  and  throat, 
the  diseases  of  the  hair,  of  the  skin,  etc.  It  is  rather  strange  to 
observe  that  in  the  various  works  of  dental  history,  i.e.,  Carabelli, 
Geist-Jacoby,  Lemerle,  Guerini,  etc.,  there  is  no  specific  reference 
found  in  regard  to  this  important  work. 

Pedanios  Dioscorides  or  Dioskurides  of  Anazarbus  (Asia  Minor) 
lived  during  the  second  half  of  the  first  century.  Nothing  definite 
is  known  concerning  his  life.  It  seems,  however,  that  at  one  time 
he  was  engaged  as  an  army  surgeon,  and  during  his  sojourn  with 
the  Roman  legions  visited  many  countries.  As  he  states  of  him- 
self, from  early  youth  he  was  passionately  fond  of  nature  study, 
and  his  love  for  botany  is  largely  responsible  for  his  minute  and 
accurate  description  of  the  many  hundred  specimens  of  vegetable 
drugs,  of  which  he  gives  a  detailed  account  in  his  "Materia  Med- 
ica."  Incidentally,  with  the  creation  of  this  work  the  term  "ma- 
teria medica"  was  introduced  into  general  medicine.  The  volume 
is  divided  into  five  books,  and  contains  nearly  one  thousand  drugs, 
primarily  of  the  vegetable  kingdom,  although  many  animal  drugs 
and  quite  a  few  mineral  compounds  are  enumerated. 

Dioscorides  has  depicted  the  medicinal  plants  so  accurately  that 
with  his  aid,  more  than  1900  years  later,  botanists  w^ere  able  to 


INTRODUCTION  27 

locate  the  greater  majority  of  these  plants  in  the  respective  coun- 
tries. For  more  than  sixteen  centuries  this  important  work  has 
formed  the  basis  of  all  teachings  in  botany  and  pharmacology. 
It  has  been  translated  into  most  of  the  languages  of  the  cultured 
nations,  and  innumerable  editions  have  appeared.  Various  epi- 
tomes and  commentaries  of  this  work  have  been  prepared,  and, 
with  the  financial  aid  of  crowned  heads  of  Europe,  beautifully  il- 
lustrated editions  have  been  printed.  In  the  various  libraries  of 
Europe  there  are  about  twelve  more  or  less  complete  codices  (manu- 
scripts) of  this  work  of  Dioscorides  preserved. 

During  a  careful  perusal  of  this  most  interesting  text,  the  writer 
has  been  able  to  locate  more  than  one  hundred  passages  referring 
to  diseases  of  the  teeth  and  their  adnexa.  Dental  historians,  wh*^n 
referring  to  the  practice  of  oral  therapeutics  of  the  early  Ro- 
man period,  invariably  cite  Scribonius  Largus  as  their  authorit3\ 
His  "de  Compositiones, "  a  medical  formulary,  written  between 
40  and  50  a.d.,  contains  several  prescriptions  for  tooth-powders 
and  quite  a  few  drugs  which  are  employed  in  dental  diseases. 
Compared  with  the  references  found  in  the  "Materia  Medica" 
and  the  "Home  Remedies"  of  Dioscorides  relative  to  dental  ther- 
apeutics, the  formulary  of  Scribonius  Largus  is  completely  out- 
shadowed. 

The  patron  saint  of  dentistry,  St.  Apollonia,  was  canonized  in 
Rome  about  300  a.d.  Being  a  Christian,  St.  Apollonia  was  tor- 
tured by  her  persecutors  by  having  her  teeth,  one  by  one,  ex- 
tracted, and  finally  suffered  death  by  fire.  Her  memory  is  com- 
memorated on  February  9th  of  each  j^ear.  Remains  of  her  skele- 
ton are  preserved  in  the  various  churches  of  Rome,  Naples,  Co- 
logne, Antwerp,  Brussels,  and  Quebec,  and  excellent  pictures  of 
the  saint  by  Guido  Reni,  Carlo  Dolci,  and  others  are  found  in 
Milan,  Florence,  and  other  cities.  The  name  of  St.  Apollonia  is 
frequently  mentioned  in  prayers  in  the  various  prayer  books  of 
the  middle  ages,  and  is  especially  intended  for  the  relief  of  tooth- 
ache. 

Prior  to  1840  comparatively  few  important  communications  on 
dental  surgery  had  appeared.  The  foremost  literature  of  this 
time  was  published  in  France  and  England,  and  a  few  books 
of  importance  appeared  in  Germany.  The  United  States  was  at 
this  period  principally  concerned  with  the  practical  development 


28  GENERAL   THERAPEUTICS 

of  this  new  branch  of  the  healing  art,  and,  with  the  exception 
of  the  writings  of  Longbotham,  E.  Parmly,  L.  S.  Parmly,  Flagg, 
Trenor,  Fitch,  Bostwick,  Spooner,  S.  Brown,  the  Burdells,  and 
others,  little  was  printed  in  relation  to  dentistry.  Dental  text- 
books, if  used  at  all,  were  imported  from  England,  or  translations 
of  French  works  were  published.  Leonard  Koecker,  a  practitioner 
of  international  reputation,  pictured  the  situation  quite  correctly 
when  he  stated,  in  1826,  that  ''in  the  United  States,  although  lit- 
tle or  nothing  has  been  done  in  the  way  of  publishing  on  the  sub- 
ject of  dental  surgery,  yet  I  feel  myself  authorized  to  say  that 
in  no  part  of  the  world  has  this  art  obtained  a  more  elevated  sta- 
tion." It  must  also  be  remembered  that  the  individual  practi- 
tioner of  this  period  was  extremely  jealous  of  any  special  knowl- 
edge Avhich  he  happened  to  possess,  and  he  usually  guarded  this 
acquired  proficiency  very  carefully.  No  specific  current  dental 
literature  was  in  existence  at  that  time,  and  comparatively  few 
medical  journals  tried  to  disseminate  the  progress  of  medical  and, 
incidentally,  dental  knowledge.  The  few  journals  Avere  seriously 
hindered  in  this  laudable  cause  by  the  extreme  difficulties  of  in- 
terchange on  account  of  the  very  limited  facilities  of  the  postal 
service.  The  first  dental  periodical  of  this  or  any  other  country 
appeared  in  1839  under  the  name  of  "American  Journal  of  Den- 
tal Science,"  and  was  published  by  E.  Parmly,  E.  Baker,  and  S. 
Brown.  The  first  regularly  organized  dental  society  of  any  im- 
portance was  the  "American  Society  of  Dental  Surgeons,"  which 
was  founded  in  New  York  on  August  18,  1840,  with  Horace  H. 
Hayden  as  president.  The  birth  of  dentistry  as  a  distinct  and 
definite  profession  may  be  recorded  simultaneously  with  the  date 
of  incorporation  of  the  first  dental  college  of  the  world,  the  Bal- 
timore College  of  Dental  Surgery,  which  received  its  charter  in 
1839.  Its  first  session  commenced  in  the  following  year,  with  a 
faculty  composed  of  Horace  A.  Hayden,  Chapin  A.  Harris,  Thomas 
E.  Bond,  and  H.  Willis  Baxley.  Medicine  and  dentistry  were 
from  that  year  practically  divorced,  and,  while  dentistry  in  its 
early  days  depended  very  largely  on  medicine  for  its  further  de- 
velopment, it  bases  its  fundamental  studies  at  present  on  general 
biology  exactly  in  the  same  manner  as  medicine,  veterinary  medi- 
cine, or  any  other  branch  of  the  healing  art  is  forced  to  do. 

Arkovj'-  has  said  that  "in  operative  dentistry,   empiric  thera- 
peutics has  reached   far  ahead   of  pathologic  knowledge."     The 


INTRODUCTION  29 

truth  of  this  axiom  finds  its  explanation,  as  we  have  stated  above, 
in  an  absence  of  organization  of  the  comparatively  few  dental 
practitioners  prior  to  1840.  No  specific  books  on  dental  remedies 
were  then  in  existence,  and  the  little  knowledge  concerning  the 
action  of  drugs  was  scattered  through  the  few  dental  works,  or 
it  was  closely  guarded  by  its  possessor.  Since  then  quite  an  ex- 
tensive literature  on  dental  materia  mcdica  and  therapeutics  has 
appeared,  which  furnishes  ample  proof  of  the  immense  stride 
made,  especially  in  the  last  decade,  in  this  particular  phase  of 
dental  science.  The  drugs  which  were  principally  applied  as  den- 
tal remedies  were  usually  such  agents  as  were  also  employed,  ac- 
cording to  their  therapeutic  indications,  for  disturbances  of  a 
similar  pathologic  nature  in  other  parts  of  the  body.  Prominent 
among  these  remedies  are  the  commoner  astringents — nutgalls,  oak 
bark,  myrrh,  alum,  etc.  Of  the  caustics,  silver  nitrate  and  the 
mineral  acids,  especially  nitric  acid,  were  much  in  vogue.  Ar- 
senic trioxid  has  always  occupied  an  important  place  in  dentistry 
as  a  powerful  caustic.  In  1836  it  was  recommended  by  Shearjas- 
hub  Spooner^  for  the  purpose  of  destroying  the  dental  pulp,  and, 
in  spite  of  the  many  substitutes  offered,  it  still  maintains  an  en- 
viable reputation  for  this  purpose.  Creosote,  and  to  a  still  greater 
extent  phenol,  which  was  discovered  by  Runge  in  1834,  have  al- 
ways been  favorite  remedies,  which  were  employed  as  caustics, 
obtundents,  and,  unwittingly,  as  antiseptics.  The  antiseptic  era 
was,  however,  inaugurated  by  Joseph  Lister  many  years  later.  Its 
birthday  may  be  registered  at  1867,  when  Lister  published  his  epoch- 
making  paper  entitled:  "On  the  Antiseptic  Principle  of  the  Prac- 
tice of  Surgery.  "2  Many  of  the  essential  oils — the  oils  of  cloves, 
cinnamon,  peppermint,  spearmint,  turpentine,  etc. — have  been  em- 
l)loyed  for  many  centuries  as  obtunding  agents  in  the  treatment 
of  pulpitis,  and  they  have  always  enjoyed  quite  a  reputation  as 
flavoring  agents  for  mouth  preparations.  Aromatic  and  analgesic 
fomentations  consisting  of  cataplasms  prepared  from  mixtures  of 
chamomile,  henbane,  poppy  heads,  hops,  ground  linseed,  or  roasted 
figs  and  bruised  raisins,  occupied  a  prominent  place  as  antiphlogis- 
tics  for  the  relief  of  inflammation  about  the  teeth  and  their  adnexa. 
Of  the  true  analgesic  drugs,  opium  and  aconite  are  probably  the 


»  Shearjashub   Spooner:     Guide  to   Sound  Teeth,   or  a  Popular  Treatise  on   the  Teeth. 
New  York,  1836. 

'British   Medical   Journal,   Aug.   8,   1867. 


30  GENERAL   THERAPEUTICS 

most  important  representatives.  Among  the  aromatic  tinctures 
and  lotions  which  were  used  as  soothing  and  healing  mouth  washes, 
alcoholic  extracts  of  balsams  and  resins — as  myrrh,  frankincense, 
benzoin,  mastic,  etc. — and  decoctions  and  infusions  of  herbs,  barks, 
and  roots — as  arnica,  anise  seed,  cloves,  cinnamon,  chamomile,  sweet 
flag,  ginger,  merigold,  scurvy  grass,  mallow,  sage,  etc. — were  in 
common  use.  Innumerable  formulas  for  tooth  powders  are  found 
in  the  older  works  pertaining  to  the  treatment  of  the  teeth,  and 
consisted  largely  of  a  base  made  from  prepared  chalk,  burnt  oy- 
ster shells,  charcoal,  crabs'  eyes,  Armenian  bole,  pumice  stone, 
etc.,  mixed  with  cuttlefish  bone,  magnesia,  vegetable  powders,  espe- 
cially spices,  and  coloring  materials. 

A  record  concerning  the  more  important  events  of  the  develop- 
ment of  dental  pharmacology  would  be  incomplete  if  the  dis- 
covery of  general  anesthesia  were  not  mentioned,  even  if  it  is 
only  en  passant.  To  the  dental  profession  of  the  United  States 
belongs  the  honor  of  having  introduced  into  surgery  the  first 
practical  method  of  obtaining  complete  anesthesia.  The  discovery 
of  anesthesia  is  the  greatest  boon  ever  bestowed  on  mankind  for 
the  relief  of  suffering.  With  the  introduction  of  nitrous  oxid 
as  a  general  anesthetic  in  1844  by  Horace  Wells,  the  stimula- 
tion for  further  researches  was  initiated,  and  the  future  develop- 
ment of  anesthesia  was  merely  a  sequence  of  this  incentive. 

THE  AIM  OF  THERAPEUTICS. 

The  object  of  medical  art  is  to  cure  disease,  to  relieve  suffering, 
and  to  maintain  health.  Aside  from  the  various  technical  means 
employed  in  relieving  the  sick,  there  are  at  the  service  of  the 
physician  hygienic  and  physical  measures,  and  the  use  of  a  num- 
ber of  substances  which,  when  applied  to  or  introduced  into  the 
body,  bring  about  decided  changes.  These  substances  are  known 
as  drugs.  The  rational  administration  of  drugs  depends  on  a 
clear  conception  of  their  physiologic  action.  It  is  supposed,  how- 
ever, that  the  physician  possesses  a  comprehensive  knowledge  of 
the  causes  which  produce  disease — general  patliology — and  that 
he  utilizes  this  knowledge  together  with  that  of  the  physiologic 
action  of  drugs  in  the  struggle  of  combating  disease. 

The  materials  and  substances  used  in  medicine  comprise  the 
animal,  vegetable,  and  mineral  kingdoms;  and  the  study  of  their 


THE    AIM   OF   THERAPEUTICS  31 

names,  sources,  physical  character,  and  chemic  properties,  their 
preparations,  doses,  etc.,  is  referred  to  as  materia  medica.  The 
term  materia  medica  as  stated  above  was  introduced  by  Dioscori- 
des.  He  published  the  first  compilation  of  descriptions  of  drugs, 
which  were  mostly  vegetable  in  character,  while  the  first  collec- 
tion of  prescriptions — a  formulary — was  edited  by  Scribonius 
Largus.  Drugs — pJiarmaca — are  remedies;  the  study  of  drugs — 
that  is,  the  changes  which  are  induced  in  the  living  organism  by 
their  administration — is  known  as  pharmacology.  A  remedy,  in 
the  broadest  sense  of  the  term,  is  anything  which  cures,  palliates, 
or  prevents  disease,  and,  consequently,  comprises  the  utilization 
of  all  means  and  methods  which  are  employed  for  the  purpose  of 
relieving  the  sick  and  favorably  influencing  the  evolution  of  dis- 
ease, while  drugs  proper  are  the  material  substances  obtained  from 
the  animal,  vegetable  and  mineral  kingdoms  employed  as  thera- 
peutic agents  to  produce  a  cure.  Drugs  are  either  pure  chemicals, 
mixed  mineral  products,  or  certain  animal  or  vegetable  substances. 
"Crude  drugs"  is  a  commercial  term  designating  natural  animal 
or  vegetable  drugs  as  they  are  brought  to  the  market.  In  a  re- 
stricted sense  of  the  word,  only  the  changes  which  are  produced 
by  the  action  of  drugs  in  the  healthy  or  diseased  organism  is  known 
as  pharmacology,  while  the  power  of  drug  action  itself  is  known 
as  pJiarmaco-dynamics.  At  the  present  time  pure  pharmacology 
is  classified  as  a  department  of  biology;  all  biologic  sciences,  how- 
ever, serve  in  some  form  or  another  as  handmaids  to  general 
medicine.  In  the  teaching  as  well  as  in  the  clinical  application 
of  pharmacology  a  number  of  questions  arise  which  indicate  its 
close  relationship  to  physiology  and  to  pathology.  Through  the 
action  of  drugs  on  normal  tissues  we  are  led  to  understand  their 
effects  on  the  disturbed  functions  of  these  tissues.  In  the  experi- 
mental study  of  antipyretics,  for  instance,  their  influence  on  the 
normal  temperature  as  well  as  on  the  increased  temperature  in 
fevers,  together  with  an  understanding  of  the  nature  of  the  lat- 
ter, is  essential  for  the  full  comprehension  of  their  therapeutic  ap- 
plication. In  its  broadest  conception,  then,  we  understand  by  phar- 
macology the  science  of  the  changes  which  occur  in  the  vital  re- 
actions of  healthy  and  diseased  tissues  under  the  influence  of 
chemic  substances.  The  application  of  remedial  substances  in  the 
treatment  of  diseased  conditions  of  the  body  is  based  on  our  knowl- 
edge of  pharmacology,  and  it  is  at  present  referred  to  as  pJiar- 


32  GENERAIi   THERAPEUTICS 

macotlierapy,  a  term  which  was  introduced  by  Kobert  (1887). 
It  constitutes  the  most  important  branch  of  therapeutics.  Some 
substances,  when  ingested  into  the  living  body,  possess  little  medic- 
inal value,  but  they  act  as  poisons  by  bringing  about  dangerous 
or  even  fatal  results.  The  study  of  their  effects  on  the  tissues 
and  the  methods  of  their  detection  is  known  as  toxicology.  It  is 
difficult  to  draw  a  distinct  line  between  a  drug  and  a  poison; 
frequently  only  the  quantity  given  and  the  method  of  its  adminis- 
tration will  determine  whether  the  substance  acts  as  a  food,  a 
drug,  or  a  poison.  The  description  of  the  drugs,  their  habitats, 
their  composition,  and  their  recognition  is  spoken  of  as  pJiarma- 
cognosy,  while  pliarmacy  is  usually  defined  as  the  art  of  prepar- 
ing medicines  for  use  and  dispensing  them  on  the  order  of  the 
therapeutist.  The  term  pharmacy  is  also  applied  to  the  place  of 
business  of  the  druggist;  the  latter  is  also  known  as  pharmacist 
or  apothecary.  The  application  of  remedial  measures  for  the 
purpose  of  relieving  the  sick  and  favorably  modifying  the  evolu- 
tion of  disease  is  referred  to  as  tkerapeuiics.  While  in  the  past 
the  administration  of  remedies  was  largely  based  on  empirical  con- 
ceptions, modern  research  endeavors  to  employ  rational  methods 
for  the  treatment  of  diseases.  By  medical  empiricism  we  under- 
stand the  treatment  of  the  sick  by  symptoms  only,  knowing  noth- 
ing of  the  disease,  while  rational  therapeutics  implies  the  basing 
of  the  treatment  on  a  thorough  knowledge  of  the  causative  factors 
of  disease.  A  few  diseases  are  directly  amenable  to  drug  action — 
as  malaria,  syphilis,  anemia,  etc. — and  the  remedies  employed  for 
such  definite  purposes  are  known  as  specifics.  Unfortunately  only 
a  very  few  of  these  specifics  are  at  our  command,  and  most  of 
them  were  discovered  by  empirical  medication.  Within  recent 
years  rational  methods  have  been  adopted  for  the  treatment  of 
certain  infectious  diseases,  which  resulted  in  the  discovery  of  def- 
inite, specific  products  known  as  antitoxins,  which  act  against  the 
disease  producing  toxins  very  much  in  the  the  same  manner  as  an 
antidote  acts  against  a  poison.  The  introduction  of  salvarsan  b}' 
Ehrlich-Hata  in  1910  as  an  etiotropic  remedy  for  the  treatment 
of  syphilis  has  marked  a  new  era  in  experimental  therapy  and  it 
is  to  be  hoped  that  this  truly  marvelous  discovery  will  lead  to 
further  specific  remedies  which  may  aid  in  the  battle  against  some 
of  the  greatest  scourges  of  the  human  race. 

It  is  not  always  possible  to  reach  the  diseased  organ  directly 


THE  AIM  OF  THERAPEUTICS  3o 

by  the  administered  remedy — that  is,  to  remove  the  causative  fac- 
tors of  the  disease.  Sometimes  it  will  be  found  that  a  disease  has 
progressed  so  far  as  to  exclude  direct  medication.  The  thera- 
peutist may,  however,  be  able  to  relieve  the  painful  symptoms,  or 
he  may  at  least  mitigate  the  conditions.  Symptomatic  treatment 
is  frequently  of  great  benefit  to  the  patient;  the  latter  is  prin- 
cipally interested  in  getting  relief  from  things  which  annoy  him, 
and  he  cares  less  about  things  which  may  be  harmful.  The  phy- 
sician must  be  able  to  judge  from  the  symptoms  which  he  recog- 
nizes in  the  diagnosis  of  the  disease  what  remedies  are  best  indi- 
cated for  his  patient ;  he  -must  know  the  best  method  of  their  ad- 
ministration, their  dose,  the  length  of  time  they  should  be  given, 
etc.  If  a  disease  has  altered,  or  even  destroyed,  a  part  of  certain 
tissues  or  their  functions,  it  does  not  necessarily  follow  that  a 
permanent  injury  must  result,  provided  that  the  work  of  the  dis- 
eased organ  is  carried  on  by  some  other  organ.  A  kidney  may  be- 
come so  affected  that  its  removal  is  indicated.  This  does  not 
necessarily  mean  that  the  patient  has  to  succumb,  as  the  other 
sound  kidney  is  sufficiently  active  to  cai'ry  on  the  work  which 
nature  had  intended  for  the  two  organs,  and  the  patient  may 
still  enjoy  fairly  good  health.  When,  however,  an  organ  is  so 
altered  by  a  disease  that  its  work  cannot  be  accomplished  by  an- 
other organ — for  example,  the  valves  of  the  heart  have  become 
weakened — drugs  may  be  administered  which  will  beneficially  in- 
fluence the  symptoms  of  this  diseased  condition,  but  they  will 
never  cure  the  ailment. 

Etiologic  and  symptomatic  therapeutics  will  be,  more  or  less, 
always  applied  simultaneously.  It  should  not,  however,  be  under- 
stood that  the  symptoms  of  diseases,  even  if  they  cause  more  or 
less  annoyance  to  the  patient,  should  be  treated  at  once  by  drug 
administration.  These  subjective  disturbances  are  frequently  re- 
active measures  of  the  organism  created  for  the  purpose  of  de- 
stroying the  disturbing  elements.  It  is  immaterial  whether  these 
disturbances  are  the  cause  of  the  disease  or  its  product.  At  pres- 
ent fever  is  generally  considered  a  means  of  self-defense  of  th'' 
disturbed  organism,  and  is  instituted  by  nature  against  the  dis- 
turbing agencies,  which  have  gained  access  to  the  tissues.  Na- 
ture may,  however,  in  her  efforts  to  battle  with  the  invading  foe, 
go  too  far,  and  the  fever  may  rise  above  104°  F,  (40°  C),  and, 
as  a  consequence,  will  endanger  not  only  the  disease  producers, 


34  GENERAL   THERAPEUTICS 

but  also  the  heart.  It  is  now  the  duty  of  the  physician  to  regu- 
late the  activity  of  self-medication  by  the  body  and  keep  it  within 
proper  channels  by  the  application  of  suitable  remedies.  Again, 
in  inflammation,  which  is  at  present  recognized  as  a  reaction  of 
the  tissues  against  an  injury,  the  preliminary  hyperemia  is  one 
of  the  foremost  means  of  self-defense  that  the  body  possesses.  The 
application  of  antiphlogistics  is  usually  counter-indicated  in  the 
early  stages  of  the  disturbances;  if  the  pain  that  accompanies  an 
inflammatory  condition  becomes  unbearable,  then  it  is  the  duty 
of  the  physician  to  counteract  the  eager  efl^orts  of  nature  by  ap- 
pljang  carefully  selected  remedies  that  will  keep  it  within  proper 
limits. 

While  modern  medicine  has  profited  extensively  by  its  associa- 
tion "with  pharmaceutic  chemistry,  it  should  not  be  forgotten  that 
the  old  and  well-tried  remedies — as  opium,  mercury,  potassium 
iodid,  digitalis,  etc. — still  hold  an  important  place  in  the  arma- 
mentarium of  the  conscientious  physician,  and  that  they  are  as 
yet  not  supplanted  by  the  so-called  modern  substitutes.  It  is  a 
false  illusion  that  only  the  new  is  valuable  and  reliable,  and  the 
old  is  a  relic  of  the  past.  On  the  other  hand,  it  should  be  remem- 
bered that  there  still  prevail  a  great  many  notions  regarding  the 
action  of  certain  remedies  which  are  not  in  harmony  with  the 
modern  rational  conception  of  the  physiologic  action  of  drugs. 
Some  of  these  ' '  pharmacologic  f etishims, ' '  as  they  have  been  very 
appropriately  termed  by  a  writer,  are  so  deeply  implanted  in  the 
minds  of  some  practitioners  that  the  latter  have  become  slaves 
in  the  blind  following  of  this  belief.  For  instance,  the  idea  of 
administering  potassium  chlorate  with  the  intention  of  exerting 
a  beneficial  influence  on  all  forms  of  diseases  in  the  mouth  by  the 
liberation  of  nascent  oxj'gen  is  wholly  unfounded.  Potassium 
chlorate  is  principally  a  blood  poison,  and  as  a  therapeutic  agent 
it  possesses  no  advantage  over  any  other  simple  salt,  as  sodium 
chlorid.  Again,  potassium  iodid  and  sulphureted  lime  are  lauded 
by  many  as  panaceas  in  the  treatment  of  disturbances  arising 
from  general  infection.  As  a  matter  of  fact,  neither  of  these 
chemicals  is  indicated  as  a  specific  in  these  conditions.  Sulphur- 
eted lime  has  no  place  in  modern  therapeutics,  and  potassium 
iodid  possesses  only  one  real  indication,  and  that  a  most  impor- 
tant one — in  certain  stages  of  syphilis. 


THE    Am    OF    THERAPEUTICS  35 

Quite  frequently  the  question  is  asked,  "Do  drugs  ever  cure?" 
Before  an  attempt  is  made  to  answer  this  question  it  is  necessary 
to  have  an  understanding  of  what  constitutes  a  "cure"  and,  inci- 
dentally, what  is  meant  by  health  and  disease.     It  does  not  mat- 
ter for  our  present  consideration  from  which  point  of  view  we 
look  upon  life.     To  us  it  means  the  reaction  of  cell  activity  of  the 
organism  as  a  whole  produced  by  various  external  agents.    When- 
over  the  normal  equilibrium  of  this  cell  activity  is  disturbed  by 
a  morbific  cause,  the  organism  reacts  against  it,  producing  a  series 
of  phenomena  which  is  known  as  disease.     Nature  possesses  as  an 
inherent  quality  the  power  of  re-establishing  normal   conditions 
— vis  medicatrix  naturce — i.e.,  to  heal  the  disease.     To  aid  nature 
in  the  reconstruction  of  her  disturbed  functions,   the   physician 
applies  remedial  agents  which  are  intended  to  "cure"  the  dis- 
ease.    Expressed  in  the  words  of  Celsus,  these  two  processes  are 
defined  as  natura  sannt,  medicus  curat.     In  the  layman's  mind 
there   is  not  the  remotest  doubt  that  a  drug  or   a  combination 
of  drugs  possesses  the  power  of  producing  a  cure.     He  takes  a 
headache  powder  with  the  definite  expectation  of  curing  his  head- 
ache.    This  very  idea  is  still  entertained  by  a  number  of  prac- 
titioners of  the  old  school,  and  it  is  largely  based  upon  the  in- 
herent popular  desire  for  drugs.     Even  Galen  complained  most 
bitterly  about  this  generally  established  notion  by  saying:     The 
people  want   prescriptions!      Since  the  first   publication   of  Vir- 
chow's   Cellular  Pathology   in    1858,    and    the    consequential    ad- 
vances made  in  experimental  pharmacology,  this  prevalent  notion 
has   greatly  changed.     It  was  shown  that  the  drugs  themselves 
had  no  direct  influence  on  the  disease  itself.     As  soon  as  this  fact 
became  known  it  Avas  quite  fashionable  to  laugh  at  the  curative 
effects  of  drugs,  thus  establishing  the  folly  of  drug  nihilism  with 
certain  erratic  physicians.     This  drug  skepticism  frequently  re- 
sults fi-om  errors  regarding  the  medicines  themselves,  or  from  im- 
proper utilization  of  drugs — at  the  wrong  time  or  in  the  wrong 
disease — or  their  definite  action  is  not  distinctly  understood.    Un- 
familiarity  with  the  fundamental  principles  of  incompatibility  is 
quite  frequently  another  case  of  drug  nihilism.     While  we  are 
aware  that  the  vis  medicatrix  naturae  is  the  profound  basis  of  a 
cure,  we  are  also  aware  that  the  action  of  the  drugs  is  materially 
instrumental  in  coaxing  nature  to  bring  about  a  change  in  the 
prevailing  conditions.    Numerous  instances  could  be  cited  to  eluci- 


36  GENERAL   THERAPEUTICS     " 

date  this  tenet.  The  physician  administers  quinin  to  his  patient 
to  kill  the  Plasmodia  malarice,  the  true  cause  of  malaria,  but  the 
many  disturbances  which  the  malaria  germs  have  produced  in 
the  various  organs  of  the  body  are  restored  by  nature.  The  den- 
tist removes  a  tooth  which  is  the  cause  of  a  purulent  infiltration 
of  the  soft  and  hard  tissues,  but  the  restoration  of  the  distorted 
tissues  and  the  healing  of  the  wound  is  accomplished  solely  by 
nature.  Or,  a  man  breaks  his  jawbone,  and  the  skillful  dental 
surgeon  puts  the  broken  parts  in  proper  position,  applies  a  splint, 
and  the  parts  unite  Avithout  leaving  the  least  trace  of  a  deformity ; 
but  without  nature's  reparative  process — without  formation  of  the 
callus — the  best  surgical  skill  would  be  of  no  avail.  Such  in- 
stances are  met  in  very  old  people,  in  whom,  in  spite  of  the  best 
treatment,  fractured  parts  refuse  to  unite.  On  the  other  hand, 
without  having  the  parts  put  in  proper  position,  a  great  deform- 
ity may  result,  or  the  fracture  may  remain  ununited  in  spite  of 
a  superabundance  of  nature's  reparative  power.  "Faith  in  the 
Gods  or  in  the  Saints  cures  one,  faith  in  little  pills  another,  hyp- 
notic suggestion  a  third,  faith  in  a  plain,  common  doctor  a  fourth. 
In  all  ages  the  prayer  of  faith  has  healed  the  sick,  and  the  mental 
attitude  of  the  suppliant  seems  to  be  of  more  consequence  than 
the  powers  to  which  the  prayer  is  addressed.  The  cures  in  the 
temples  of  Esculapius,  the  miracle  of  the  Saints,  the  remarkable 
cures  of  those  noble  men,  the  Jesuit  missionaries,  in  this  country, 
the  modern  miracles  of  Lourdes,  and  the  wonder-workings  of  the 
so-called  Christian  Scientists  are  often  genuine  and  must  be  con- 
sidered in  discussing  the  foundation  of  therapeutics."  (Osier.) 
The  young  graduate,  fresh  from  college,  usually  starts  out  with 
a  long. list  of  drugs,  ready  to  combat  all  diseases.  When  he  gets 
his  first  patient  with  some  difficult  ailment,  where  drug  adminis- 
tration is  indicated,  he  finds  that  the  remedy  which  he  has  cho- 
sen is  utterly  incapable  of  influencing  the  existing  conditions; 
his  faith  receives  a  severe  shock,  and  usually  tumbles  down  to 
a  disbelief  in  drug  action.  A  small  number  of  drugs,  meeting 
the  every-day  indications,  should  be  employed  in  the  bulk  of  a 
dentist's  work.  Constant  acquaintance  familiarizes  him  \vith  their 
nature  and  their  uses,  and  with  these  few  remedies  his  best  work 
is  usually  done.  Therapeutic  nihilism  is  just  as  erroneous  as  the 
polypharmaceutic  shotgun  prescription  of  our  ancestors.  Prac- 
titioners of  large  experience  usually  obtain  the  best  result  with 


NATURE    OF   DRUG    ACTION  37 

a  few  of  the  simple  remedies,  while  many  of  the  younger  dis- 
ciples of  Esculapius  seize  after  new  compounds  because  they  do 
not  know  how  to  employ  either  of  them.  "When  called  to  guide 
a  patient  through  an  illness,  the  physician  should  be  constantly 
a  watchman,  and  a  therapeutist  only  when  necessity  arises." 

NATURE  OF  DRUG  ACTION. 

Within  the  last  fifty  years  the  theories  regarding  the  pharmaco- 
logic action  of  drugs  have  undergone  remarkable  changes.  Em- 
piricism in  medicine  has  held  sway  ever  since  remedies  were  used 
for  the  purpose  of  alleviating  diseases,  and  it  was  only  through 
the  introduction  of  experimental  pharmacology  in  the  early  six- 
ties of  the  last  century  that  a  slow  but  radical  change  in  the  ad- 
ministration of  drugs  took  place.  The  science  of  modern  phar- 
macology is  based  on  Virchow's  conception  of  cellular  pathology, 
and  with  its  introduction  into  general  medicine,  in  1858,  the  hu- 
moral pathology  of  Hippocrates  received  its  death-blow.  In  the 
conception  of  this  great  physician  of  Cos,  Hippocrates,  the  knowl- 
edge of  medicine  was  based  on  seven  natural  phenomena — res  nat- 
urales — and  he  considered  the  body  as  being  made  up  of  the  four 
elements,  i.e.,  fire,  earth,  air,  and  water.  These  elements  were 
supposed  to  invest  the  body  with  the  proper  temperaments  (com- 
plexiones)  the  heat,  the  cold,  the  dry,  and  the  wet,  which  when 
combined  in  different  proportions  in  the  different  individuals  were 
productive  of  the  four  humors,  i.e.,  the  blood  (sanguis),  the  phlegm 
(phlegmon),  the  yellow  bile  (clioler),  and  the  black  bile  (mel- 
ancholer).  It  was  further  supposed  that  one  or  the  other  of 
these  humors  must  always  be  present  in  a  preponderance,  so  as 
to  create  the  specific  physical  organization  which  is  peculiar  to 
the  respective  individual. 

According  to  the  ruling  fashion — and  the  practice  of  medical 
art,  including  its  stepdaughter,  dentistry,  has  always  been  gov- 
erned by  it — the  remedies  employed  in  treating  diseases  were  in 
accordance  with  the  predominating  school.  The  number  of  rem- 
edies which  are  at  the  disposal  of  the  physician  are  countless;  the 
drugs  of  real  merit,  however,  may  be  gathered  within  a  small  com- 
pass. In  the  Ebers  papyrus,  for  instance,  which  comprises  the 
period  3700  to  1500  B.C.,  about  eight  hundred  remedies  are  enu- 
merated, and  Dioscorides  describes  about  a  thousand  drugs.    Again, 


38  GENERAL   THERAPEUTICS 

in  the  Pharmacopoeia  Medico-physica,  published  by  Schroder  in 
1664,  the  goodly  number  of  six  thousand  remedies  is  recorded. 
We  may  probably  gain  a  better  understanding  of  the  use  of  these 
many  drugs  when  we  remember  that  about  that  period  polyphar- 
macy had  reached  its  zenith.  In  those  daj^s  the  combination  of 
ten,  twenty,  or  even  more  simples  in  a  single  prescription  was 
very  much  of  a  routine  practice.  For  instance,  such  mystic  com- 
pounds as  theriaea  and  mithridate,  which  enjoyed  a  world-wide 
reputation  in  their  days  as  ' '  cure-alls, ' '  were  concocted  of  seventy- 
five  or  even  more  simples.  The  London  pharmacopeia  of  1667 
published  a  formula  for  the  preparation  of  a  mithridate  confectio 
damocratis — which  called  for  eightA'-five  different  ingredients  in 
its  make-up.  A  recent  example  of  polypharmacy  is  the  still  fa- 
mous Warburg's  tincture,  which  originally  called  for  some  twenty- 
odd  simples  for  its  preparation. 

The  action  of  drugs  on  the  organism  is  known  only  in  a  very 
few  instances.  After  a  drug  is  absorbed  by  the  tissues,  a  chemic 
reaction  between  this  substance  and  the  protoplasm  of  the  cell 
occurs,  which  is  generically  expressed  as  irritation.  What  con- 
stitutes this  irritation  and  its  subsequent  reaction  with  the  dis- 
eased organism  is  as  yet  unknown.  Apparently  all  pharmacol- 
ogic action  is  governed  by  the  same  biologic  law  which  controls 
every  manifestation  of  the  living  cell,  i.  e. :  Minute  irritation 
augments  vital  function,  medium  irritation  increases  the  same, 
strong  irritants  lower  these  functions  and  the  strongest  irritation 
changes  them  completely.  The  degree  of  irritation  is  purely  a 
matter  of  individuality  and,  incidentally,  a  supposed  primary  de- 
pression will  alwaj's  be,  relatively  speaking,  an  irritation. 

The  basic  laAv  governing  pharmacologic  action  may  be  expressed 
as  follows:  Drugs  ingested  into  the  body  must  he  sohihle  in  the 
tissue  fluids  in  order  to  combine  with  the  cell  contents  and  there- 
by exercise  their  function.  This  axiom,  well  known  to  the  ancient 
medical  chemists,  was  dogmatically  expressed  as:  Corpora  Twn 
agunt  nisi  soluta  seu  solubilia.  In  other  words,  pharmaco-dyna- 
mic  action  is  the  result  of  a  chemic  reaction  between  the  drug  and 
the  living  organism.  However,  the  term  "chemic"  in  this  particu- 
lar instance  must  not  be  restricted  to  narrow  bounds;  the  reac- 
tion between  the  drug  and  the  cell  contents,  i.e.,  albumin,  lecithin, 
salts,  water  and  other  compounds  usually  is  not  of  a  pure  chemic 
nature  but,  in  most  instances,  a  phy.sieo-ehomic  process  in  which 


NATURE    OF    DKU(i    ACTION  39 

diffusion,  filtration  and  osmotic  pressure  play  important  parts. 
It  may  be  explained  as  a  process  of  dissociation  of  a  complicated 
group  of  molecules  into  simpler  ones  or  even  into  ions,  brought 
about  or  facilitated  by  the  presence  of  specific  ferments  or  enzymes 
and  accompanied  by  hydrolytic  decomposition,  oxidation,  reduc- 
tion, precipitation,  substitution,  synthetization  or  other  compli- 
cated procedures.  The  term,  solubility  in  the  tissue  fluids,  car- 
ries with  it  a  far-reaching  significance  and  its  initial  conception 
must  not  be  based  on  similes  observed  outside  of  the  body.  Ex- 
pressed in  simple  language,  the  results  of  a  test  tube  experiment 
must  not  be  interpreted  as  producing  similar  reactions  within  the 
living  organism.  As  a  well-known  example  we  may  cite  the  phar- 
macologic action  of  calomel.  The  mild  mercurous  chlorid  is  in- 
soluble in  the  ordinary  fluids  in  the  test  tube ;  when  administered 
internally,  however,  even  in  the  so-called  broken  doses,  i.e.,  one- 
tenth  of  a  grain,  marked  therapeutic  effects  are  observed.  The 
result  of  the  calomel  action  is  not  to  be  explained  on  the  mechani- 
cal basis  of  its  mere  presence,  but  it  is  the  sequence  of  its  enter- 
ing into  solution  through  the  agencies  of  the  tissue  fluids.  Whether 
minute  quantities  of  the  readily  soluble  sublimate  are  formed  or 
whether  intermediary  products  are  resultant  from  the  albumin- 
sodium  ehlorid-enzyme,  etc.,  action  is  of  less  importance  at  this 
moment.  The  mere  fact  remains  that  the  otherwise  insoluble  cal- 
omel does  enter  into  solution  when  brought  in  contact  with  the 
living  cells  and  hence  by  its  physico-ehemic  reaction  is  capable 
of  bringing  about  profound  therapeutic  effects. 

Certain  drugs  apparently  react  with  all  the  cells,  while  others 
possess  an  elective  action  to  specific  cell  groups.  To  produce  phar- 
macologic action,  an  adequate  amount  of  the  drug,  constituting  its 
average  dose,  is  essential.  Only  an  immeasurably  small  portion 
of  the  administered  drug  reacts  with  the  specifically  susceptible 
cells.  After  absorption,  the  blood  and  the  lymph  stream  distribute 
the  drug  throughout  the  whole  body  and,  depending  on  its  spe- 
cial affinity,  it  is  retained  by  the  various  cells.  Apparently,  no 
direct  relationship  exists  between  the  quantity  of  the  absorbed 
drug  and  its  elective  pharmacologic  action,  i.e.,  as  yet  we  have  no 
more  conception  why  a  grain  of  strychnin  will  kill  a  sound,  healthy 
man  within  a  few  minutes  after  absorption  than  why  a  spark  fall- 
ing into  a  barrel  of  gunpowder  will  cause  its  explosion.  Two  def- 
inite factors  apparently  play  an  important  role  in  the  therapeutic 


40  GENERAL   THERAPEUTICS 

action  of  drugs — first,  the  power  possessed  by  the  drug  itself,  and, 
second,  the  reactive  power  possessed  by  the  organism.  Recent 
experimental  observations  seem  to  point  to  the  fact  that  patho- 
logically altered  tissues  react  quite  differently  to  chemic  substances 
than  do  normal  tissues,  and  that  the  condition  of  the  organism, 
within  certain  limits,  determines  whether  the  same  pharmacologic 
action  will  produce  good  or  bad  results.  The  irritation  produced 
by  the  absorbed  drug  manifests  itself  as  stimulation  or  as  depres- 
sion of  the  function  of  the  organism.  These  reactions  depend 
largely  on  it?  dose  and  on  the  age,  sex,  and  individuality  of  the 
patient.  Some  drugs,  when  ingested  in  small  quantities,  increase 
the  bodily  functions,  while,  when  taken  in  large  doses,  decrease 
the  same  function.  Again,  certain  drugs  exercise  specific  influ- 
ence on  certain  organs.  All  changes  which  occur  within  the  tis- 
sues as  a  result  of  the  action  of  a  drug  are  of  a  chemic  nature. 
Usually  three  forms  of  reaction  between  the  drug  and  the  cell 
of  the  body  are  recognized: 

1.  A  superficial  combination  between  the  cell  wall  and  the 
chemic  substance  occurs,  which  lasts  as  long  as  the  cell  is  active 
and  is  not  injured.  The  chemic  substance  does  not  enter  into  the 
protoplasm  of  the  cell  proper. 

2.  A  combination  of  the  chemic  substance  and  the  cell  con- 
tents is  produced  as  a  result  of  the  easy  penetration  of  the  sub- 
stance into  the  protoplasm  proper. 

3.  A  combination  is  formed  between  the  chemic  substance  and 
the  protoplasm  which  lies  intermediate  between  the  first  and  sec- 
ond group — that  is,  it  may  require  minutes,  or  even  days,  before 
this  combination  is  obtained. 

Nature  will  alwaj^s  hold  its  own  as  far  as  the  supremacy  of 
drug  influence  is  concerned — it  will  always  react  against  drug 
action  as  long  as  it  possesses  vitality.  If  the  tissue  does  not 
possess  sufficient  strength  to  resist  the  action  of  the  drug,  death 
is  the  result,  while,  if  the  diseased  tissue  wins  the  battle  by  in- 
creased reaction  against  the  drug,  it  will  return  to  its  normal 
function. 

All  drugs  that  are  ingested  into  the  body  are  again  removed 
from  it  by  the  secretions  and  excretions.  This  process  depends 
largely  on  the  stability  of  the  union  which  the  drug  has  formed 
with   the  tissues.      Some   drugs   show   a   predilection   for   certain 


NATURE   OF   DRUG    ACTION  41 

glands  for  their  removal — as,  mercury  is  largely  removed  by  the 
salivary  glands,  potassium  iodid  through  the  glands  on  the  mucous 
membrane  of  the  eyes,  etc. 

Dose.— The  Ninth  Decennial  Revision  (1916)  of  the  Pharma- 
copeia of  the  United  States  has  again  admitted  average  approxi- 
mate doses  of  medicine  for  adults  to  be  used  internally  or  hypo- 
dermically.  These  doses  are  not,  however,  obligatory  on  the  phy- 
sician, and  they  may  be  increased  or  reduced  according  to  cir- 
cumstances. It  is  a  matter  of  clinical  experience  with  each  prac- 
titioner to  safely  adjust  the  dose  for  the  case  in  hand.  In  using 
a  powerful  remedy,  it  is  best  to  start  with  a  small  dose  and  in- 
crease cautiously.  Various  circumstances  modifying  the  dose  de- 
mand attention. 

Age. — Children  and  the  aged  require  smaller  doses  than  the 
adult.  The  following  rule  of  Dr.  Young  is  now  almost  universally 
adopted :  For  children  under  twelve  years  the  dose  of  most  med- 
icines must  be  reduced  in  the  proportion  of  the  age  to  the  age 
increased  by  twelve,  i.e.,  twelve  is  added  to  the  child's  age  and 
the  same  is  divided  by  the  age.    For  example,  at  two  years  the 

dose  is  reduced  to  1/7  (2+12)  =  ^/''  ^^  ^+1^  =  ^^^^  =  '''•  "^^^ 
adult  dose  divided  by  7  is  the  proper  dose  for  the  child. 

Frequency  and  Time. — The  effect  derived  from  the  medicines 
is  largely  the  guiding  post  of  frequency  and  time  at  which  they 
should  be  taken.  Purgatives  are  usually  taken  in  a  single  dose  in 
the  morning;  emetics  are  to  be  taken  once,  and  repeated  only  in 
case  vomiting  is  not  induced ;  drugs  which  induce  sleep  are  nat- 
urally given  at  bedtime;  alkaline  stomachics,  before  meals;  tonics, 
three  times  a  day  continuously.  The  interval  between  the  doses 
should  be  calculated  and  the  second  dose  administered  before  the 
effect  produced  by  the  first  has  passed  off.  The  daily  dose  is  three 
times  as  large  as  the  single  dose.    The  exceptions  are: 

If  the  single  dose  is  =  V2  grain,  the  daily  dose  is  =  2  grains. 
If  the  single  dose  is  =  2  grains,  the  daily  dose  is  =  8  grains. 
If  the  single  dose  is  =  4  grains,  the  daily  dose  is  =  15  grains. 
If  the  single  dose  is  =  25  grains,  the  daily  dose  ia  =  IV2  drams. 

The  daily  dose  is  twice  that  of  the  single  dose: 

1.  Of  all  strychnin  preparations, 

2.  Of  all  hypnotics  (sulfonal,  veronal,  trional,  etc.), 

3.  Of  pilocarpin  hydrochlorid,  and 


42  GENERAL   THERAPEUTICS 

4.     Of  all  single  doses  of  50  grains  or  more. 

In  estimating  the  maximum  daily  dose,  the  day  is  to  be  counted 
as  24  hours. 

Sex,  Temperament,  Idiosyncrasy,  and  Tolerance. — Females  and 
persons  of  sanguine  temperament  require  somewhat  smaller  doses 
than  males  and  the  phlegmatic.  Certain  persons  exhibit  peculiar 
pronounced  reactions  toward  ordinary  doses  of  drugs  while  others 
may  take  much  larger  doses  without  any  ill  effect.  This  char- 
acteristic state  of  individuality  is  referred  to  as  idiosyncrasy.  As 
yet  no  satisfactory  explanation  of  this  peculiarity  has  been 
brought  forward.  It  is  well  known  that  apparently  normal  in- 
dividuals will  quicldy  react  to  extremely  small  doses  of  calomel, 
opium,  antipyretics,  etc.  Again,  certain  foods  exhibit  unusual  re- 
actions in  certain  persons,  as,  for  instance,  crawfish,  strawberries, 
raspberries,  etc.  Occasionally  it  is  observed  that  an  individual 
apparently  does  not  react  to  the  ordinary  dose  of  a  medicine,  i.e.. 
tolerance  to  the  drug  is  recognized.  The  prolonged  use  of  a 
drug,  i.e.,  morphin,  arsenic,  cocain,  etc.,  may  establish  an  acquired 
tolerance  known  as  drug  habit.  The  most  familiar  examples  of 
acquired  tolerance  are  those  of  tobacco,  alcohol,  coffee  and  tea. 
Some  drugs— as  calomel,  chloral  hydrate,  and  arsenic — are  pecul- 
iarly well  borne  by  children,  being  taken  by  them  in  relatively 
large  doses.  On  the  other  hand,  children  are  peculiarly  suscep- 
tible to  the  influence  of  opium.  Again,  many  drugs — as  ipecac- 
uanha, tartar  emetic,  alcohol,  etc. — have  different  action  in  dif- 
ferent doses. 

Cumulative  Effect  and  Synergy. — Drugs  ma.v  be  given  at  longer 
or  shorter  intervals,  depending  on  many  circumstances.  Custom, 
habit,  and  tolerance  play  the  most  important  part.  Occasionally 
in  the  administration  of  drugs,  it  will  be  observed  that  after  a 
number  of  doses  have  been  taken  with  no  apparent  or,  but  slight, 
effect  that  sudden  symptoms  arise  which  are  much  more  pro- 
nounced than  those  manifested  after  the  first  dose.  This  effect  is 
referred  to  as  cumulative  action  of  drugs.  Absorption  may  be 
more  rapid  than  excretion  and  each  new  dose  thus  adds  to  the 
total  quantity  present  in  the  blood  and  in  the  different  organs  of 
the  body.  A  classic  example  is  digitalis,  although  strj^chnin, 
atropin,  arsenic,  iodids,  etc.,  are  known  to  induce  this  state  of 
cumulative  action.  The  metal  salts,  especially  those  of  mercury, 
lead,  copper  and  silver  are  productive  of  chronic  poisoning  by 


NATURE    OF   DRUG    ACTION  43 

these  cumulative  effects.  In  most  cases,  except  in  those  of  the 
metal  salts,  the  retardation  will  last  only  a  few  days,  rarely 
weeks,  while  arsenic,  mercury,  lead,  etc.,  may  remain  for  months; 
silver,  under  suitable  conditions,  may  be  retained  for  years  or 
even  permanently  in  the  system.  Frequently  mixtures  of  drugs 
of  which  each  individual  substance  is  known  to  produce  the  same 
effect  in  the  body,  are  administered  to  induce  increased  action — 
a  cooperation  of  the  powers  known  as  synergy.  The  synergistic 
effect  of  mixtures  of  purgatives  offers  a  striking  example ;  the  mix- 
ture acts  usually  distinctly  more  efficiently  than  any  one  drug  of 
the  same  mixtures  given  in  quantity  equal  to  all  of  them.  Of 
great  practical  importance  is  the  synergism  of  the  narcotics,  i.e., 
the  combined  effects  of  scopolamin  and  morphin,  or  morphin  and 
ether,  etc.  Mixtures  of  the  antiseptics  of  the  benzol  ring  series 
with  other  groups  exhibit  marked  synergistic  action,  as  formo- 
cresol.  Drugs  when  administered  simultaneously  may  antagonize 
each  other,  i.e.,  they  are  physiologically  incompatible.  (See  hi- 
compatihilities.)  Occasionally  it  will  be  observed  that  the  in- 
gestion of  drugs,  and,  to  some  extent,  ai'ticles  of  food,  are  fol- 
lowed by  a  peculiar  form  of  skin  eruption,  known  as  drug  rash 
(dermatitis  medicamentosa).  This  disturbance  may  be  the  result 
of  ingesting  an  excessive  amount  of  the  drug  or  to  an  idiosyncrasy 
of  the  individual.  The  most  common  drug  dermatoses  are  those 
following  the  ingestion  of  bromids  and  iodids,  although  quinin, 
salicylic  acid  and  many  other  drugs  and  articles  of  food,  as  straw- 
berries, buckwheat  and  shell  fish  are  known  to  produce  this  dis- 
ease. The  prolonged  use  of  mouth  preparations  (washes,  powders 
and  pastes)  containing  appreciable  quantities  of  such  skin  irri- 
tants as  salicylic  acid,  salol,  menthol,  and  essential  oils  are  oc- 
casionally productive  of  morbiliform  eruptions  about  the  corners 
of  the  mouth  or  the  lower  lip  in  susceptible  patients.  These  erup- 
tions are  generically  known  as  mouth  Avash  eczema.  Formalin 
is  prone  to  cause  a  most  persistent  and  painful  eczematous  erup- 
tion about  the  liands  of  the  dentist. 

The  remarkable  achievements  made  by  the  progress  of  or- 
ganic chemistry  have  materially  aided  the  rapid  development  of 
pharmaeo-therapeutics.  The  discovery  of  the  active  constituents 
of  plants,  the  alkaloids,  and  their  preparation  in  a  pure  state 
has  furnished  the  physician  with  a  great  many  A^ery  important 
medicinal  agents,  which  are  now  used  by  him  in  preference  to 


44  GENERAL.   THERAPEUTICS 

the  crude  drugs.  The  discovery  of  the  chief  alkaloid  of  opium — 
morphin — by  SertUrner,  in  1805,  marked  a  new  era  in  pharma- 
ceutic chemistry.  It  was  rapidly  followed  by  the  discovery  of 
atropin  in  belladonna  leaves,  cocain  in  coca  leaves,  strychnin  in 
nux  vomica,  etc.,  and  at  present  there  are  probably  very  few 
medicinal  plants  of  which  the  active  constituents  have  not  been 
isolated.  These  alkaloids  allow  an  accurate  dosage,  and,  to  in- 
crease the  rapidity  of  their  action,  Alexander  AVood,  in  1855, 
introduced  an  important  chaaige  in  their  administration^ — the 
hypodermic  method.  The  analysis  of  the  alkaloids  has  led  the 
way  to  the  discovery  of  a  number  of  synthetic  compounds  which 
proved  to  be,  in  some  instances  at  least,  superior  to  the  action 
of  the  natural  alkaloids  in  the  treatment  of  disease.  For  instance, 
after  the  chemic  constituents  of  cocain  had  been  positively  worked 
out,  various  groupings  of  the  original  molecules,  with  certain  ad- 
ditions and  omissions,  furnish  the  many  synthetic  cocain  sub- 
stitutes which  since  have  proved  to  be  of  even  greater  value  than 
the  original  cocain.  This  is  also  time  of  many  antipyretics,  anti- 
septics, diuretics,  diaphoretics,  and  a  host  of  similar  synthetic 
substances. 

The  newer  remedies  which  have  been  introduced  into  materia 
medica  within  the  last  forty  years  owe  their  discovery  almost 
exclusively  to  the  chemic  laboratory.  They  were  discovered,  not 
by  accident,  but  by  definite,  previously  outlined  experimental 
work.  The  introduction  of  chloral  hydrate  as  a  hypnotic  by 
Liebreich,  in  1869,  was  probably  the  first  step  in  modern  experi- 
mental pharmacology.  Lauder  Brunton,  in  1867,  introduced 
amyl  nitrite  for  the  purpose  of  lowering  the  blood  pressure;  in 
1884  Filehne  discovered  antipyrin,  which  was  soon  followed  by 
acetanilid,  phenacetin,  and  numerous  other  antipyretics.  Not 
alone  had  plant  alkaloids  to  furnish  their  quota  of  remedial 
agents,  but  the  various  glands  of  the  animal  had  to  give  up  their 
active  constituents  for  the  treatment  of  disease.  In  1894  Oliver, 
Schafer,  and  Moore  discovered  the  blood  pressure  raising  principle 
of  the  suprarenal  capsules,  and  since  then  a  number  of  similar 
organo  preparations  have  found  their  way  into  modern  therapy. 

CLASSIFICATION  OF  DENTAL  REMEDIES. 

The  first  systematic  classification  of  drugs  according  to  their 
pharmacologic  action  was  introduced  by  Buchheim  in  1856,  and 


CLASSIFICATION    OF   DENTAL   REMEDIES  45 

since  the  appearance  of  "Dei*  Gruiidriss  der  Arzneimittellehre, " 
by  Schmiedeberg,  in  the  early  eighties  of  the  last  century,  a  revo- 
lution in  drug  medication  has  taken  place.  This  revolution  was 
made  possible  only  by  the  complete  elimination  of  empiricism,  and 
by  utilizing  the  results  obtained  from  experimental  work  on  healthy 
and  artiJEicially  diseased  animals,  and,  to  some  extent,  on  man. 
Aside  from  the  above-named  experimenters,  such  men  as  Magen- 
die,  Beaumont,  Claude  Bernhard,  B.  W.  Richardson,  Crum  Brown, 
Frazer,  Binz,  Liebreich,  Lauder  Brunton,  Filehne,  Kobert,  Ehr- 
lich,  Cushny,  Abel,  Heinz,  Pawlow,  and  others  too  numerous  to 
mention,  have  paved  the  way  in  the  past  or  are  still  actively  en- 
gaged in  solving  the  intricate  problem  of  drug  action,  and  thereby 
have  created  a  new  branch  in  biological  science  known  today  as 
experimental  therapy.  Unfortunately  the  dental  profession  has 
been  slow  in  keeping  pace  with  the  progress  made  in  general  phar- 
macology, and  as  a  consequence  there  is  still  much  empiricism  in- 
volved in  the  practice  of  dental  medicine.  Broadly  speaking, 
there  is  no  excuse  for  such  laxity.  The  last  decade  offers  ample 
proof  of  the  immense  effort  which  has  been  made  to  place  dental 
therapeutics  on  a  rational  basis;  yet  many  notions  prevail  in  the 
minds  of  some  practitioners  regarding  the  action  of  certain  rem- 
edies which  are  not  in  harmony  with  the  modern  conception  of 
the  physiologic  action  of  drugs.  The  stereotyped  prescriptions 
which  are  so  often,  displayed  in.  current  dental  literature,  and  the 
consequent  practice  of  "making  the  disease  fit  the  remedy,"  are 
much  to  blame  for  this  pharmacologic  idolatry.  Even  some  of 
the  text-books  persist  in  the  transmission  of  certain  antiquated 
views  in  regard  to  the  therapeutic  action  of  drugs.  Very  recently 
the  writer  had  occasion  to  look  over  many  hundred  questions  re- 
lating to  the  subject  of  materia  medica  and  therapeutics  as  asked 
by  various  state  boards,  and  he  was  rather  surprised  at  the  pe- 
culiar conception  of  pharmaco-therapy  which  these  questions  dis- 
played on  the  part  of  the  examiners. 

A  systematic  classification  of  drugs,  i.e.,  a  classification  into 
groups  according  to  Buchheim-Schmiedeberg,  which  should  serve 
the  needs  of  the  dental  practitioner,  as  has  been  suggested  by 
some  theorists,  is  from  a  didactic  as  well  as  a  practical  point  of 
view  a  total  failure.  The  practice  of  dental  medicine  is  a  spe- 
cialized field  of  the  healing  art  which  utilizes  not  merely  drugs 
but  any  rational  method  and  means  which  may  be  of  service  in 


46  GENERAL   THERAPEUTICS 

the  curing  of  disease  or  in  the  alleviation  of  its  symptoms.  In 
his  endeavor  to  present  a  record  of  the  action  of  drugs  and  their 
application  and  other  remedial  measures  which  are  employed  by 
the  dental  practitioner,  the  writer  has  grouped  the  various  agents 
according  to  the  viewpoint  of  the  pharmaco-therapeutist,  i.e.,  it  is 
his  desire  in  the  rational  consideration  of  their  application  to  com- 
bine pharmacologic  research  with  clinical  observation.  Conse- 
quently no  definite  line  of  demarcation  can  be  drawn  between  the 
various  groups.  The  chief  divisions  are  so  arranged  as  to  best 
serve  the  clinical  practitioner,  and  not  the  theoretical  pharma- 
cologist. To  facilitate  the  ready  comprehension  of  the  various 
classes,  an  introduction  explaining  the  general  action  of  the  rem- 
edies under  discussion  precedes  each  group. 

The  largest  group  of  the  medicinal  substances  that  are  used 
bj^  the  dentist  in  his  clinical  practice  are  drugs  that  exercise  no 
definite  action  on  specific  organs.  The  disturbances  of  the  oral 
cavity  that  lie  within  the  province  of  the  dental  practitioner  are 
principally  of  an  infectious  nature,  and  consequently  the  agents 
that  are  emploj'ed  to  combat  septic  influences — the  antiseptics — 
form  the  most  important  group  of  dental  remedies.  Antiseptics, 
in  their  action,  are  so  closely  related  to  caustics  and  astringents 
that  it  is  often  merely  a  question  of  quantity  (concentration  of 
the  solution),  and  not  of  quality,  that  governs  the  primarily  de- 
sired effect.  All  precipitants  of  albumin  are  classed  as  astrin- 
gents, and  in  relatively  concentrated  solutions  they  act  as  caus- 
tics. Hand  in  hand  with  the  destruction  of  the  protoplasm  of 
the  cell  of  the  individual  goes  the  destruction  of  the  unicellular 
organisms  found  in  or  about  the  cell — the  bacteria  —and  as  a  con- 
sequence these  same  remedial  agents  act  in  most  cases  incidentally 
as  antiseptics.  Again,  astringents,  when  applied  to  bleeding  sur 
faces,  exercise  specific  functions  which  are  designated  as  hemo- 
static or  styptic  action.  Aside  from  their  chemic  action,  hemo- 
statics or  styptics  often  afford  mechanical  protection  to  the  de- 
nuded surfaces,  and  they  are  therefore  closely  related  to  protee- 
tives  and  emollients.  In  connection  with  the  protectives  we  may 
class  those  agents  which  remove  the  exciting  cause  of  disturb- 
ance— antacids,  irritants,  and  counterirritants.  To  restore  the 
equilibrium  of  the  oral  cavity,  and  incidentally  to  act  purely  for 
cosmetic  purposes,  the  many  mouth  specialties — washes,  powders, 
pastes,  soaps,  bleaching  agents,  etc.— are  employed. 


CLASSIFICATION    OF   DENTAL    REMEDIES  47 

Aside  from  their  general  action,  certain  drugs  exercise  specific 
functions  on  definite  organs  or  sets  of  organs^on  the  peripheral 
nerves,  the  central  nervous  system,  the  gastro-intestinal  canal,  the 
circulation,  the  respiration,  metabolism,  the  secretions,  etc.  Most 
of  the  morbid  disturbances  and  almost  all  of  the  operations  which 
form  an  integral  part  of  the  work  of  the  dental  surgeon  are  ac- 
companied by  more  or  less  pain.  To  be  able  to  relieve  pain  is  one 
of  the  greatest  triumphs  of  modern  pharmacology,  and  the  re- 
markable achievements  of  present-day  conservative  dentistry  are 
largely  to  be  credited  to  the  possibilities  of  mitigating  pain.  Hence 
local  anesthetics,  general  anesthetics,  and,  in  the  broadest  sense 
of  the  word,  hypnotics,  anodynes,  and  sedatives,  deserve  a  detailed 
discussion.  The  mouth  is  the  main  gateway  to  the  body;  dis- 
eases present  in  the  mouth  may,  under  certain  conditions,  be  the 
cause  or  the  result  of  disturbances  of  its  continuity^ — the  gastro- 
intestinal canal.  The  more  important  functions  of  this  continuity 
must  be  understood  by  the  broad-minded  dental  practitioner,  and 
he  should  possess  a  fair  knowledge  of  those  drugs  which  influence 
the  respective  pathologic  disturbances — stomachics,  emetics,  ca- 
thartics, etc.  Changes  in  the  circulation  which,  according  to  con- 
ditions, require  either  depressants  or  stimulants,  and  those  which 
influence  respiratory  activity  necessitate  for  their  treatment  cer- 
tain drugs  which  form  an  integral  part  of  the  general  pharmaco- 
logic knowledge  possessed  by  the  dentist.  The  influence  of  the  lat- 
ter groups  of  drugs  is  especially  of  significance  in  the  administra- 
tion of  anesthetics  and  other  powerful  poisons.  A  fair  acquaint- 
ance with  drugs  that  exercise  special  functions  on  tissue  changes — 
tonics,  alteratives,  etc. — and  on  the  secretions  of  the  body — sialo- 
gogues,  diaphoretics,  diuretics,  uric  acid  solvents — is  necessarily  of 
importance. 

Within  recent  years  so-called  biologic  therapeutics — the  use  of 
animal  products  or  those  obtained  from  bacterial  activity — have 
become  powerful  adjuncts  to  modern  materia  medica.  These  ther- 
apeutic possibilities  are  classed  under  the  general  heading  of  or- 
gano  and  serum  therapy.  While  our  knowledge  of  biologic  prod- 
ucts is  still  in  its  infancy,  an  acquaintance  with  their  general  prin- 
ciples and  their  possibilities  in  the  treatment  of  specific  dental  ail- 
ments— pyorrhea  alveolaris — is  essential  to  the  progressive  practi- 
tioner. 

In  addition  to  the  administration  of  drugs,  the  treatment  of  den- 


48  GENERAL   THERAPEUTICS 

tal  lesions  frequently  requires  other  remedial  applications,  which 
are  classed,  for  want  of  a  better  term,  as  physical  therapeutics. 
The  most  remarkable  achievements  attained  with  Bier's  hyperemic 
treatment  in  general  diseases  has  led  to  its  adoption  in  dental  sur- 
gery, and  the  truly  astonishing  results  produced  by  it  lead  us  to 
believe  that  it  will  play  an  important  role  in  the  future  practice 
of  oral  therapeutics.  The  application  of  massage,  light,  heat,  cold, 
and  other  physical  measures  as  therapeutic  considerations,  as  well 
as  the  plugging  of  bone  cavities  with  inert  or  medicated  materials, 
which  has  been  recently  introduced,  should  also  be  fully  under- 
stood. 

Classification  of  Dental  Remedies. 

I.    Drugs  Which  Exercise  No  Definite  Action  on  Specific 

Organs. 

Antiseptics : 

Salts   of  the  Heavy  Metals,   their   Oxids,   and  their  Organic 
Compounds. 

The  Acids,  the  Alkalies,  the  Halogens  and  their  Derivatives. 

Solutions  which  evolve  Nascent  Oxygen. 

Antiseptics  of  the  Aromatic  Series. 

Antiseptics  of  the  Marsh  Gas  Series. 

Essential   Oils,   their  Derivatives,  and  their  Synthetic   Substi- 
tutes 
Astringents : 

Metallic  Astringents. 

Vegetable  Astringents. 
Caustics : 

Liquid  Caustics. 

Dry  Caustics. 
Hemostatics  and  Styptics: 

Absorbents. 

Caustics  and  Astringents. 

Agents  Which  Act  After  Being  Absorbed  Into  the  Circulation. 

Agents  Which  Act  on  the  Vessels,  but  Not  on  the  Blood. 
Protectives,  Demulcents,  and  Emollients. 
Irritants  and  Counterirritants. 
Antacids. 


CLASSIFICATION    OF    DENTAL    REMEDIES  49 

II.    Drugs  Which  Act  on  Specific  Organs 

Drugs  WJiicJi  Act  on  the  Moutli  and  Teeth. 

Bleaching  Agents. 

Preparations  for  the  Mouth  and  Teeth. 
Drugs  Which  Act  on  the  Peripheral  Nerves. 

Local  Anesthetics  and  Obtundents. 
Drugs  Which  Act  on  the  Central  Nervous  System. 

General  Anesthetics. 

Hypnotics. 

Anodynes. 

Sedatives. 

Cerebral  Stimulants. 
Drugs  Which  Act  on  the  Gastrointestinal  Canal. 

Stomachics  and  Digestives. 

Emetics. 

Cathartics. 
Drugs  Which  Act  on  the  Circulation. 

Circulatory  Stimulants  and  Depressants. 
Drugs  Which  Act  on  the  Respiration. 

Respiratory  Stimulants  and  Depressants. 
Drugs  Which  Act  on  Metabolism. 

Tonics. 

Alteratives. 
Drugs  Which  Act  on  the  Secretions. 

Sialogogues  and  Antisialogogues. 

Diaphoretics. 

Diuretics. 

Uric  Acid  Solvents. 
Drugs  Which  Act  on  the  Temperature. 

Antipyretics. 
Organo  and  Serum  Therapy. 

Organo  Therapy. 

Serum  Therapy.    . 

Ill,     Physical  Therapeutics. 

Artificial  Hyperemia. 

Massage. 

Light  Therapy. 


50 


GENERAL   THERAPEUTICS 


Heat  and  Cold. 

Plugging  Bone  Cavities  -with  Inert  or  Medicated  Substances. 

Ionic  Medication. 

The  drugs  used  by  the  dentist  in  his  clinical  practice  are  usual- 
ly of  a  very  potent  nature.  On  an  average,  only  minute  quan- 
tities are  employed  in  a  single  application.  To  obtain  the  best 
results  from  the  pharmacologic  action  of  drugs,  it  is  essential 
to  procure  the  purest  materials  obtainable.  For  many  reasons 
it  is  good  policy  to  order  drugs  in  original  containers  from  a  re- 
liable manufacturer.  Drugs  and  chemicals  that  are  obtained 
from  an  open  stock  have  frequently  deteriorated.  For  example, 
the  essential  oils  are  usually  found  to  be  thick,  viscid,  and  dis- 


Fig.    1. 

Office  preparation  bottles.     Fig.  1,  dropping  bottle;  Fig.  2, 
salt-mouth  bottle. 

colored;  oxygen  compounds  may  have  lost  most  of  their  oxygen 
from  frequent  exposures  to  moist  air ;  zinc  oxid  may  have  changed 
to  zinc  carbonate  by  absorbing  carbon  dioxid  from  the  air;  coal 
tar  creosote  is  often  substituted  for  beechAvood  creosote;  cresol 
is  more  or  less  always  of  a  poor  quality;  formaldehyd  solution 
has  often  lost  most  of  its  gaseous  constitutent,  etc.  Inefficient 
drugs  as  applied  in  the  treatment  of  dental  diseases  are  Avorse 
than  dull  instruments;  both  are  sequences  of  neglect  and  should 
be  eliminated  from  the  carefully  adjusted  armentarium  of  the 
conscientious  practitioner.  It  is  gratifying  to  learn  that  the 
dental  profession  is  shoAving  a  groAving  interest  in  the  phar- 
macologic action  of  drugs  and  in  their  rational  application.    The 


CLASSIFICATION    OF   DENTAL   REMEDIES 


51 


Fig.    3. 
Aseptic    nieclicanient   tray.      (S.    S.    White.) 


=^^„m 


^^ 


practitioner  of  toda}^  is  discarding  untrustworthy  and  feeble 
remedies  and  ready  made  compounds  and  is  depending  more  and 
more  on  those  drugs  whose  efficiency  has  been  clin- 
ically established. 

Drugs,  chemicals  pharmaceutic  preparations,  etc., 
must  be  carefully  stored  if  one  wishes  to  preserve 
their  potency.  The  original  containers  should  be 
kept  in  a  cool  place,  protected  from  light.  The  office 
preparation  bottles  are  preferably  selected  from 
stoclc  made  of  colored  glass — blue,  green,  or  amber 
color- — to  keep  out  the  rays  of  light.  For  liquid 
preparations  the  dropping  bottles  (Fig.  1),  are  best 
adapted,  while  for  semi-solid  and  dry  materials  the 
glass  stoppered  salt-mouth  bottles  (Fig.  2)  are  very 
serviceable.  Office  preparation  bottles  may  now  be 
procured  with  indestructible  labels,  which  materially 
assist  in  keeping  the  containers  neat  in  appearance. 
In  using  drugs  or  chemicals,  the  necessary  quantity 
is  preferably  placed  on  a  glass  slab  or  a  watch  crys- 
tal, and  then  applied,  instead  of  dipping  the  instru- 
ment directly  into  the  bottle.    This  latter  method  is 


Fig.   4. 
Dental    applicator. 


Fig.    5. 
The    Miller 
pyorrhea  pen. 


especially  to  be  condemned  with  regard  to  anesthetic  solutions,  ad- 
renalin solutions,  and  other  liquids  which  are  easily  contaminated 


52  GENERAL   THERAPEUTICS 

or  decomposed.  For  applying  the  various  solutions  of  power- 
fully acting  drugs — phenol,  sulphuric  acid,  iodin,  silver  nitrate, 
etc. — the  author  advises  a  looped  iridio-platinum  wire  inserted 
into  a  metallic  handle,  which  is  readily  sterilized  in  an  open  flame. 
By  bending  the  wire  in  the  desired  direction,  any  tooth  surface 
in  the  month  may  be  reached.  A  number  of  these  applicators  of 
various  sizes  should  be  kept  on  hand  for  convenient  use.  The 
"Miller  Pyorrhea  Pen"  is  equally  useful  for  the  same  purposes 
and  deserves  to  be  recommended. 


SELECTION  OF  THE  REMEDY. 

After  the  diagnosis  of  a  disease  is  made,  the  proper  remedy  is 
selected.  Depending  on  the  nature  of  the  disease,  a  psychic,  a 
physical,  a  hygienic,  a  surgical  (mechanical),  or  a  pharmacologic 
method  is  chosen  for  the  treatment  of  the  ailment.  Usually  a 
combination  of  two  or  more  methods  is  employed.  No  sharp  line 
of  demarcation  can  be  drawn  between  the  various  groups  of  rem- 
edial agents,  and  a  division  of  the  whole  subject  matter  therefore 
meets  with  difficulties.  Medicine  is  not  an  abstract  science — it 
has  its  fashions  and  its  schools.  In  the  early  days  of  medical  prac- 
tice the  Greek  and  Roman  schools  were  predominating,  and  the 
pharmacologic  treatment  consisted  principally  of  the  use  of  in- 
numerable pharmaceutic  compounds  of  vegetable  drugs,  which 
to  this  day  are  known  as  galenic  preparations  (named  after  Ga- 
len). The  Arabian  physicians  continued  the  same  practice,  but 
added  to  the  materia  medica  a  number  of  new  organic  and  inor- 
ganic compounds,  which  were  prepared  by  their  chemists  or  were 
accidentally  discovered  by  the  alchemists.  With  the  introduction 
of  iatrochemistry  into  medicine  by  Paracelsus,  the  galenic  prepa- 
rations and  the  methods  of  treatment  of  the  Greek  and  Arabian 
physicians  received  a  severe  setback.  When  on  St.  John's  Day, 
in  1527,  Paracelsus  burned  publicly  on  the  market  place  of  Basel 
the  works  of  Celsus,  Galen,  Avicenna,  and  others,  exclaiming, 
"I  have  burnt  all  these  books  so  that  all  misery  may  be  carried 
away  with  their  smoke,"  a  new  era  had  dawned  in  scientific  med- 
icine. During  the  seventeeth  and  eighteenth  centuries  a  com- 
plete change  of  the  practice  of  therapeutics  was  inaugurated. 
which  started  almost  simultaneously  in  various  parts  of  Europe. 
Sydenham,  of  London  (1660)  ;  Boerhaave,  of  Leyden,  (1720)  ;  Van 


SELECTION    OF   THE   REMEDY  53 

Swieten,  of  Vienna  (1745)  ;  Hoffmann,  of  Halle  (1725),  and  Stahl, 
of  Berlin  (1730),  were  the  most  influential  reformers,  and  their 
names  are  indelibly  inscribed  on  the  historic  pages  of  the  prog- 
ress of  modern  therapeutics.  The  growing  tendency  of  overdrug- 
ging  received  a  severe  check  through  the  introduction  of  Hahne- 
mann's (1810)  method  of  treating  diseases  with  very  small  doses, 
which,  combined  with  other  extreme  changes  in  therapeutics,  re- 
sulted in  the  foundation  of  the  homeopathic  school.  No  definite 
knowledge  regarding  drug  action  had  become  available  to  the 
practicing  physician,  and,  as  a  consequence  of  the  empiric  ad- 
ministration of  drugs,  it  became  customary  to  poke  fun  at  those 
who  regarded  drugs  necessary  in  the  treatment  of  diseases.  Espe- 
cially Skoda  and  Dietl  (1830  to  1870),  of  the  Vienna  school,  ex- 
pressed erratic  views  in  regard  to  drug  medication,  and  both  ex- 
tremists carried  the  idea  of  drug  nihilism  to  such  an  extent  as  to 
almost  eliminate  materia  mediea  from  the  curriculum  of  the  study 
of  medicine.  Dietl  was  wont  to  express  his  extreme  skepticism  re- 
garding the  action  of  drugs  in  this  dogmatic  statement,  "There 
are  no  real  therapeutics — there  are  only  lucky  physicians."  Bear- 
ing in  mind  the  fact  that  no  tangible  knowledge  of  pharmacology 
existed  at  that  time,  our  judgment  of  these  outbursts  of  overzealous 
minds  is  materially  modified  when  we  consider  that  even  at  this 
day  the  drugless  "Christian  scientist"  and  the  supporter  of  the 
"Emmanuel  movement"  hold  sway  over  the  minds  of  the  cred- 
ulous. 

To  designate  the  various  methods  of  therapeutic  measures,  the 
term  iatro  (from  the  Greek  iatros,  the  physician)  is  used  as  a  pre- 
fix in  signifying  its  connection  with  the  healing  art.  Therapeutic 
methods  may  be  conveniently  divided  into: 

1.  Physical  Therapeutics,  or  latrophysics. — They  include  the 
physical  and  hygienic  means  and  methods  employed  as  remedies 
—as  light,  heat,  cold,  electricity,  climate,  exercise,  and  health 
resorts. 

2.  Mechanical  Therapeutics,  or  latromechanics. — They  are  rep- 
resented by  massage,  gymnastics,  orthopedics,  and  the  instruments 
utilized  in  the  performance  of  surgical  operations. 

3.  Psychologic  Therapeutics,  or  latropsychics. — They  are  prin- 
cipally concerned  with  the  psychologic  influences  exercised  by  the 
physician  on  the  patient.    Especially  are  nervous  diseases  amen- 


54  GENERAL   THERAPEUTICS 

able  to  this  method  of  treatment,  although  certain  bodily  func- 
tions may  also  be  materially  influenced  by  the  method. 

4.  Chemic  (physiologic)  Therapeutics,  or  latrochemistry — 
They  include  the  feeding,  the  many  spas,  and,  finally,  the  great 
mass  of  drugs  proper. 

METHODS  OF  ADMINISTERING  MEDICINES. 

Medicines  may  be  administered  by  any  of  the  accessible  tissues 
or  cavities  of  the  body,  and  the  mode  of  administration  very  often 
determines  the  effect  of  the  remedy.  In  general  remedies  may 
be  applied  locally,  or  topically,  and  internally.  The  former  are 
usually  intended  to  produce  local  effects,  while  the  latter,  through 
their  absorption  into  the  blood,  produce  general  action.  Relative 
to  the  general  action  of  drugs,  it  should  be  remembered,  as  we 
have  stated  above,  that  a  drug  must  be  in  solution  or  in  vapor 
form  to  produce  its  action.  The  solution  which  brings  the  drug 
to  interact  with  the  protoplasm  of  the  cells  should  be  so  con- 
stituted as  to  be  readily  soluble  in  the  body  juices.  Consequently 
the  quickest  action  of  a  drug  is  obtained  when  it  is  dissolved  in 
a  solution  equal  in  its  density  to  a  physiologic  salt  solution.  In 
certain  cases  retarded  absorption  is  important,  and  therefore  col- 
loidal substances,  and  sometimes  fatty  substances,  are  added  to 
the  solution.  Retarded  action  usually'  goes  hand  in  hand  with 
prolonged  effects. 

In  the  administration  of  medicines  usually  one  of  the  foUow'- 
ing  methods  is  selected: 

By  inunction  and  fumigation ; 

By  the  mouth  or  stomach; 

By  the  rectum; 

By  hypodermic  injection; 

By  inhalation ; 

By  inoculation,  and 

By  cataphoresis  (ionic  medication). 

Local  action  of  remedies  is  expected  when  they  are  applied  to 
the  skin,  to  the  mucous  membrane  of  the  alimentary,  respiratory, 
and  genito-urinary  tracts,  to  the  eye,  and  to  the  teeth.  The  skin 
is  protected  with  the  horny  layer  of  the  epidermis  and  with  seba- 
ceous secretions,  which  prevent  the  ready  penetration  of  aqueous 
solutions.    Oily  or  fatty  substances  mix  readily  with  the  sebaceous 


METHODS   OF   ADMINISTERING    MEDICINES  55 

matter  of  the  skin.  If  friction  is  applied,  the  substances  may 
penetrate  through  the  outer  layer  and  even  into  the  deeper  struc- 
tures. Diffusible  and  volatile  substances — as  chloroform,  ether, 
alcohol,  essential  oils,  etc. — penetrate  comparatively  quickly  and 
may  reach  the  blood.  The  application  of  remedies  to  the  skin 
with  the  object  of  producing  general  action  is  largely  discarded 
at  present,  although  inunctions  with  mercury  ointment  is  still  in 
favor  with  some  practitioners.  Kemedies  applied  to  the  skin  to  pro- 
duce local  effects  are  principally  used  to  act  on  some  local  disturb- 
ance. Blisters,  poultices,  liniments,  plasters,  powders,  lotions,  col- 
lodions, etc.,  are  examples  of  local  medicaments.  Occasionally 
absorption  of  the  drug  will  occur,  and  general  action  is  produced. 
The  mucous  membranes  quickly  absorb  aqueous  solutions  of 
drugs,  while  fatty  substances  have  very  little  action  on  these 
tissues.  If  an  ointment  is  applied,  the  moist  surface  must  be  pre- 
viously carefully  dried.  Mucous  membranes  are  much  more  sus- 
ceptible to  drugs  than  the  unbroken  skin,  and  very  quick  action 
is  usually  obtained  in  the  mouth  from  their  ready  absorption,  as 
the  rich  blood  supply  of  the  oral  tissues  favors  ready  dissemina- 
tion. In  applying  solutions  to  the  sensitive  mucous  surfaces,  it 
should  be  remembered  that  isotonic  solutions  produce  the  least 
irritation.  If  the  drugs  themselves  do  not  produce  an  isotonic 
solution,  the  addition  of  one  per  cent  of  sodium  chlorid  readily 
accomplishes  the  purpose.  The  application  of  remedies  to  the 
mucous  membranes,  with  the  exception  of  those  of  the  stomach 
and  the  intestines,  is  principally  intended  for  their  local  action. 
Drugs  are  administered  as  solutions,  paints,  powders,  mixtures, 
solids,  or  in  vapor  form.  Diseases  of  the  mouth  and  throat  are 
treated  with  mouth  Avashes,  gargles,  paints,  lozenges,  powders,  and, 
sometimes,  salves.  Inhalations  of  vaporized  medicines  are  also 
used  in  the  treatment  of  oral  disease.  For  the  latter  purposes  a 
paraffin  vehicle  is  not  advisable.  The  mouth  washes  are  employed 
with  a  gargling  motion  .  (See  Mouth  Washes.)  Paints  should  be 
applied  with  a  toothpick  wound  with  cotton,  and  caustic  or  cor- 
rosive liquids  with  a  glass  rod,  or  preferably  with  a  small  looped 
iridio-platinum  wire.  Powders  are  often  used  with  a  powder 
blower  (insufflator),  and  powders  having  starch  as  a  base  are  used 
with  some  advantage  in  the  oral  cavity.  They  absorb  moisture 
and  form  a  mucilaginous  cover  over  the  diseased  surfaces.  Small 
plasters  over  the  roots  of  the  teeth  ai-e  frequently  used.    The  mu- 


56  GENERAL   THERAPEUTICS 

cous  surfaces  should  be  carefully  dried  prior  to  an  application. 
Poultices  in  the  form  of  cut  figs  or  raisins,  steeped  in  hot  water, 
are  placed  over  an  offending  tooth  root,  and  held  in  place  by  the 
cheeks  or  lips.  The  application  of  medicines  to  the  teeth  is  of  a 
specific  nature  and  is  referred  to  in  the  discussion  of  the  various 
remedies.  The  larynx  and  pharynx  are  treated  by  inhalation,  in- 
sufflation, and  by  applications  made  with  probes,  syringes,  etc., 
and  the  nasal  mucous  membrane  receives  its  medication  through 
douches,  insufflations,  bougies,  and  specific  applications.  The 
treatment  of  the  other  mucous  surfaces — conjunctiva,  bladder, 
urethra,  etc. — is  of  no  special  interest  to  the  dental  practitioner. 
The  alimentary  canal  is  the  most  common  route  for  the  ad- 
ministration of  remedies.  The  remedies  that  are  given  by  the 
mouth  may  act  locally  on  the  stomach  and  intestines,  or  they  may 


Fig.   6. 
Powder  blower. 

act  by  being  absorbed  into  the  blood.  Most  remedies  are  given 
in  aqueous  solution,  or  in  mixtures,  emulsions,  etc.,  for  the  pur- 
pose of  increasing  their  ready  absorption.  Nauseous,  ill-tasting 
medicines,  or  those  prepared  for  special  purposes  or  for  conveni- 
ence, are  given  in  pills,  powders,  capsules,  cachets,  confections, 
troches,  etc.  Relatively  speaking,  medicines  are  slowly  absorbed 
from  the  stomach.  They  are  usually  diluted  with  the  gastric 
juice,  unless  they  chemically  interact  with  it,  and  are  gradually 
passed  into  the  small  intestines,  where  absorption  takes  place, 
depending  on  certain  conditions.  Oils  and  fats  pass  in  most  cases 
unaltered  through  the  stomach,  and  are  emulsified  and  changed 
further  by  the  pancreatic  juice.  If  it  is  intended  to  protect  the 
medicines  against  the  action  of  the  gastric  juice,  they  are  usually 
administered  in  pill  form  and  coated  with  some  substance  that  is 
insoluble  in  the  gastric  fluids — as  keratin,  salol,  etc.  Occasionally 
indications  arise  that  prohibit  the  administration  of  remedies  by 
the  mouth.     Disturbances  of  this  nature  may  interfere  with  the 


METHODS   OF   ADMINISTERING    MEDICINES 


57 


act  of  swallowing — as  stricture  of  the  esophagus,  gastric  or  in- 
testinal diseases,  surgical  procedures,  etc. 

The  mucous  membrane  of  the  rectum  is  sometimes  selected  as  a 
means  of  absorbing  remedies  and  foods.  Substances  soluble  in 
water,  or  those  which  may  be  transformed  into  soluble  materials, 
are  preferably  employed  for  such  purposes.  An  injection  into  the 
rectum  (enema,  clyster)  varies  in  quantity,  and  depends  on  the 
specific  purposes  for  which  it  is  intended.  A  nutrient  enema 
•isually  measures  from  four  to  six  ounces,  while  simple  injections 
intended  for  local  action  may  measure  from  one-half  to  two  pints. 
Glycerin  injections,  which  are  strongly  irritating  Avhen  used  in 
large  quantities,  are  usually  given  in  one  to  two-dram  doses. 


Fig.  7. 
Glaseptic   hypodermic   syringe    (Parke,   Davis   &    Co.)    in   case. 

The  hypodermic  method  is  usually  applied  to  introduce  medi- 
cines in  aqueous  solutions  into  the  subcutaneous  areolar  tissues, 
from  which  a  solution  is  quickly  absorbed.  A  special  syringe,  car- 
rying a  sharp,  hollow  needle,  is  used  for  this  purpose.  Hypo- 
dermic injections  were  introduced  by  Alexander  Wood  in  1853. 
The  syringes  used  at  present  are  modifications  of  the  one  de- 
signed by  the  French  surgeon,  Pravaz;  hence  the  name  Pravaz 


58 


GENERAL   THERAPEUTICS 


syringe,  a  term  which  is  still  in  common  use  in  continental  Europe. 
About  the  body  the  needle  is  inserted  into  the  integument  by  hold- 
ing a  fold  of  the  skin  between  two  fingers,  but  not  pinching  it. 
The  least  sensitive  parts  of  the  body  should  be  selected — the  back, 
the  rear  part  of  the  thigh,  or  the  arm.  Care  should  be  exercised 
not  to  inject  air  into  the  tissues.  The  injection  into  the  oral  tis- 
sues necessitates  detailed  description.  (See  Technique  of  the  In- 
jection.) The  hypodermic  method  possesses  great  advantages,  as 
precise  doses  of  powerful  alkaloids  can  be  quickly  administered, 
avoiding  possible  reactions  between  the  drugs  and  the  contents  of 


Fig.    8. 
Steam  atomizer. 


the  stomach.  The  solutions  should  always  be  made  fresh  from 
sterile  water,  or,  still  better,  from  an  isotonic  salt  solution,  which 
materially  lessens  the  pain  of  the  hypodermic  injection.  The 
skin  at  the  place  of  injection  should  be  cleansed,  and  aseptic  care 
must  be  taken  to  avoid  infection,  as  otherwise  abscesses  are  sure 
to  follow.  The  quantity  of  solution  injected  is  usually  limited  to 
15  to  30  drops  (1  to  2  C.c),  although  antitoxic  sera  frequently 
require  larger  doses.  The  absorption  takes  place  very  rapidly 
along  the  Ij'mph  canals  and  into  the  capillaries,  and  usually  a 


METHODS   OF   ADMINISTERING    MEDICINES  59 

typical  drug  effect  is  obtained  within  a  few  minutes.  The  same 
dose  of  medicine  administerd  in  solution  by  the  mouth  would 
require  half  an  hour  or  more  before  the  action  could  be  demon- 
strated. Intramuscular  injection  is  sometimes  resorted  to,  and  is 
usually  restricted  to  oily  or  aqueous  solutions  of  irritant  drugs. 
Intravenous  injection  (transfusion,  hypodermoclysis)  is  occasion- 
ally practiced,  and  it  consists  in  injecting  directly  into  a  vein.  It 
is  most  frequently  employed  for  the  transfusion  of  blood  or  for 
the  injection  of  a  large  quantity  of  physiologic  saline  solution  for 
the  purpose  of  restoring  the  quantity  of  blood  after  severe  hemor- 
rhage, or  securing  excretions  in  certain  intoxications — as  in  uremia, 
diabetic  coma,  etc.  The  endermic  metJiod  is  employed  to  obtain  a 
rapid  action  of  a  remedy,   and  consists  in  raising  a  blister  by 


Fig.  9. 
Hand  atomizer. 

stronger  water  of  ammonia,  or  by  a  blistering  plaster,  and,  after 
cutting  away  the  raised  epidermis,  sprinkling  the  drug  on  the  ex- 
posed surface.  This  method  is,  however,  only  of  historical  in- 
terest at  present.  The  enepidermic  metJiod  endeavors  to  bring 
about  the  absorption  of  drugs  through  the  skin  by  simple  con- 
tact without  friction,  and  chloroform  and  solutions  of  drugs  in 
oleic  acid  (oleats)  are  used  for  such  purposes.  In  the  epidermic 
method,  or  inunction,  the  remedy  is  usually  employed  in  the  form 
of  an  ointment,  oil,  etc.,  with  friction  to  promote  the  passage 
through  the  epidermis. 

Inhalations  arc  employed  in  the  administi'ation  of  remedial  sub- 
stances into  the  upper  air  passages  or  into  the  lung  by  active 


60  GENERAL   THERAPEUTICS 

inspiration.  Substances  in  vapor  form,  or  in  very  fine  division 
in  the  form  of  fumes  or  clouds,  are  inhaled,  and  thus  brought  into 
close  contact  with  the  diseased  surfaces,  or,  by  ready  absorption, 
they  act  on  the  general  system — as  in  general  anesthesia.  In  the 
latter  case  special  apparatus  (masks,  etc.)  are  necessary,  while 
a  spray  (atomizer)  conveys  the  medicine  into  the  posterior  part  of 
the  mouth. 

Inoculation  is  employed  for  the  purpose  of  introducing  medici- 
nal agents  through  the  scraped  or  punctured  skin   (vaccination). 

The  application  of  medicines  by  cataplioresis,  also  known  as 
ionic  medication,  is  discussed  under  Physical  Therapeutics. 

Apparently  there  is  still  some  misunderstanding  as  to  whether 
a  dentist  has  the  legal  right  to  administer  drugs  intended  for  sys- 
temic treatment.  While  there  is  no  specific  legislation  on  this 
particular  question,  the  courts  in  the  United  States  and  Great 
Britain  have  uniformly  held  that  the  registered  dental  practitioner 
has  the  right  to  employ  such  therapeutic  measures,  including 
drugs,  as  may  be  needed  for  the  relief  of  suffering,  or  to  produce 
curative  results,  in  dental  disorders.  The  qualified  dentist  is  fully 
entitled  to  prescribe  drugs  for  local  or  general  disorders  which 
bear  a  direct  relationship  to  the  practice  of  dental  surgery,  includ- 
ing the  administration  of  anesthetics.  Dentistry,  in  the  broadest 
sense  of  the  term,  is  "a  special  department  of  the  science  and  art 
of  healing,  embracing  a  knowledge  of  the  structures,  physiology, 
and  pathology,  and  the  therapeutic,  surgical,  and  mechanical  treat- 
ment of  the  mouth  and  its  contained  organs ;  also  a  knowledge 
of  the  materials  used  and  their  manipulation  in  the  restoration 
of  the  dental  and  oral  structures."     (Kirk.) 

The  evolution  of  the  medical  specialist  within  the  province  of 
the  general  practitioner  received  its  present  impetus  with  the  dawn 
of  the  nineteenth  century  through  the  introduction  of  specific  re- 
search. However,  even  in  the  remotest  periods  of  medical  history 
we  meet  with  examples  in  which  physicians  confined  their  activity 
to  the  treatment  of  special  diseases.  Apparently  there  has  always 
existed  a  desire  on  the  part  of  the  general  practitioner  to  limit 
the  field  of  his  usefulness  to  the  care  of  disturbances  of  single  or- 
gans or  to  the  treatment  of  specific  ailments.  Herodotus,  for  in- 
stance, makes  a  very  positive  assertion  regarding  the  specialization 
among  the  Pastophores,  i.e.,  the  Egyptian  physicians.  He  states 
that:     "Medicine  is  practised  among  them  (the  Egyptians)  upon 


METHODS    OF    ADMINISTERING    MEDICINES  61 

a  plan  of  separation;  each  physician  treats  a  single  disease  and 
no  more.  Thus  the  country  swarms  with  medical  practitioners, 
some  undertake  to  cure  diseases  of  the  eye,  others  of  the  head, 
others  again  of  the  teeth,  others  of  the  intestines,  and  some  others 
which  are  not  local."  In  the  early  writings  of  the  Zend-Avesta, 
definite  instructions  are  given  to  the  surgeon,  i.e.,  "that  he  must 
first  thrice  essay  his  skill  upon  a  slave  or  on  a  lower  caste  of  man 
before  operating  upon  their  betters."  Among  the  Greeks  med- 
ical specialists  apparently  were  of  common  occurrence.  Plato 
in  "The  Charmides"  records  the  following  pertinent  complaint 
as  made  by  Socrates  regarding  the  increased  tendency  of  special- 
ization: "And  this  is  the  reason  why  the  cure  of  many  diseases 
is  unknown  to  the  physicians  of  Hellas,  because  they  are  igno- 
rant of  the  whole,  which  ought  to  be  studied  also,  for  a  part  can 
never  be  well  unless  the  whole  is  well."  Similar  conditions  pre- 
vailed among  the  Romans;  their  leading  physicians  were  either 
native  Greeks  or  they  had  received  their  medical  education  on 
Greek  soil.  To  receive  proper  recognition  by  the  medical  fraternity 
it  was  essential  for  the  young  practitioner  of  ancient  times  to  in- 
clude in  his  curriculum  a  pilgrimage  to  the  world-famous  shrine 
of  knowledge,  the  University  of  Alexandria.  From  the  time  of 
its  foundation  by  Alexander  the  Great,  about  320  b.c,  to  its  de- 
struction by  Omar,  a.d.  641,  this  exalted  seat  of  learning  exer- 
cised a  most  wholesome  influence  on  the  higher  types  of  educa- 
tion in  all  its  branches  of  the  then  known  civilized  world.  The 
paralyzing  influence  of  the  medieval  age  on  scientific  matters  in 
general  impressed  its  stamp  of  retardation  also  indelibly  on  the 
development  of  medicine.  The  only  bright  star  in  this  period  of 
orthodox  despotism  is  the  appearance  of  Paracelsus,  the  Luther 
of  Medicine,  as  he  has  been  appropriately  christened. 

Fortunately,  medicine  has  had  its  renaissance.  With  the  re- 
organization of  the  Vienna  Medical  School  by  Van  Swieten,  in 
1750,  scientific  research  received  a  reverberating  impulse,  and  its 
vibrations  are  felt  to  this  very  day.  Laryngology  saw  its  birth 
in  1855  with  the  introduction  of  the  laryngoscope,  more  or  less 
simultaneously,  by  Garcia,  Czermak  and  Tuerck;  although  Liston 
had  stated  in  1837  that  "the  existence  of  the  swelling  of  the  laryn- 
geal  mucosa  can  often  be  ascertained  by  means  of  a  speculum ; 
by  such  a  glass  as  is  used  by  the  dentists  on  a  long  stalk  previously 
dipped  in  hot  water,"  etc.     The  dental  mirror,  by  the  way,  the 


62  GENERAL   THERAPEUTICS 

most  utilitarian  instrument  of  our  whole  armentarium,  was  intro- 
duced about  1800  by  Chevalier  Bartholomeo  Ruspini,  a  promi- 
nent Italian  dentist  then  practicing  in  London.  There  seems  to 
be  sufficient  evidence  to  assume,  however,  that  the  Roman  sur- 
geons at  the  beginning  of  the  Christian  era  used  such  an  instru- 
ment for  the  inspection  of  the  oral  cavity.  The  divorcing  of 
ophthalmology  from  surgery  was  largely  brought  about  by  the 
fundamental  operative  work  of  von  Grafe  (1850)  in  which  he 
was  materially  aided  by  the  discovery  of  the  ophthalmoscope  by 
Helmholz  in  1851.  About  this  period  the  knowledge  of  diseases 
of  the  ear  was  placed  upon  a  rational  basis  by  Politzer  and  Gruber, 
and  Hebra  founded  the  science  of  dermatology.  The  diseases  of 
the  teeth  and  their  adnexa  can  by  reason  of  special  fitness  best 
be  treated  by  the  dentist.  The  oral  cavity  is  his  chosen  field  and 
Magitot's  much  coveted  desideratum:  ''Tout  dentiste  doit  etre 
medecin  et  tout  medecin  doit  etre  dentiste"  will  always  remain  a 
sincere  wish. 

At  present  dentistiy  is  regarded  as  a  distinct  profession.  It  is 
closely  related  to,  but  not  identical  with,  medicine  and  surgery. 
A  dentist  is,  therefore,  not  to  be  classified  as  a  specialist  of  a 
branch  of  medicine.  To  be  a  specialist  means  to  be  "one  who 
has  a  special  knowledge  of  some  particular  subject ;  thus,  ophthal- 
mologist, neurologist,  or  gynecologist  is  a  specialist  of  medicine." 
(Century  Encyclopedia.)  In  other  words,  to  be  a  medical  spe- 
cialist means  to  be  primarily  the  possessor  of  that  knowledge,  ac- 
cording to  the  conception  of  the  law,  which  entitles  one  to  prac- 
tice medicine  in  all  its  branches  by  virtue  of  the  state  medical 
license.  Some  courts  have  held  that  dentistry  is  a  specialty  of 
medicine.  In  the  opinion  of  the  Supreme  Court  of  Minnesota, 
in  the  case  of  State  vs.  Tajdor,^  a  person  holding  a  state  medi- 
cal license  can  not  practice  dentistry  under  the  statutes  of  that 
state.     The  following  is  a  synopsis  of  the  decision  in  that  case: 

"For  reasons  of  public  policy,  with  which  the  Court  has  no  particular  con- 
cern, the  Legislature  adopted  the  policy  of  dividing  the  field  of  medicine  and 
surgery,  and  making  a  separate  profession  of  a  part  thereof.  It  was  thought 
that  men  who  engaged  in  the  treatment  of  diseases  of  the  dental  organs 
should  receive  special  preparation  and  be  specially  licensed  to  practice  that 
particular  branch  or  department  of  medicine  and  surgery.  A  State  Board  of 
Dental   Examiners   was   created   and   authorized   to   determine   who   should   be 


» Journal  of  A.  M.   A.,    1909,  p.    122. 


PRESCRIPTION    WRITING  63 

licensed  and  entitled  to  practice  dentistry  in  the  state.  A  department  of 
Dental  Surgery  was  also  established  at  the  University  (of  Minnesota),  with 
a  course  of  study,  the  satisfactory  completion  of  which  would  entitle  the  stu- 
dent to  a  special  degree  of  Dental  Surgery.  An  examination  of  this  course 
shows  that  it  includes  a  considerable  part  of  the  work  required  in  the  med- 
ical school,  but  it  also  includes  studies  which  relate  particularly  to  diseases 
of  the  dental  organs  and  others  designed  to  insure  efficiency  in  the  mechanical 
work  connected  with  the  treatment.  From  an  examination  of  the  statutes  of 
other  states  relating  to  the  practice  of  dentistry,  the  Court  learns  that  many 
contain  express  exceptions  in  favor  of  physicians  and  surgeons.  Probably  the 
most  of  them  permit  physicians  to  extract  teeth,  or  perform  such  other  com- 
paratively simple  work.  In  the  absence  of  any  such  exceptions,  it  must  con- 
clude that  the  Legislature  intended  to  restrict  the  scope  of  the  practice  of 
the  physician  and  surgeon,  and  require  him,  if  he  desires  to  practice  dentistry, 
to  obtain  a  license  from  the  State  Board  of  Dental  Examiners  in  addition  to 
his  other  certificate." 

PRESCRIPTION  WRITING. 

A  prescription,  from  the  Latin  prae  (before)  and  scriho  (I 
write),  may  be  defined  as  a  written  order  for  medicines  sent  by  a 
qualified  medical,  dental  or  veterinary  practitioner  to  a  pharmacist. 
Prescriptions  are  termed  simple  if  containing  but  one  ingre- 
dient, and  compound  if  containing  more  than  one.  Aside  from 
ingredients  which  are  used  to  give  the  requisite  form  to  medicines, 
such  as  solvents,  diluents,  and  excipients,  drugs  may  be  combined 
in  prescriptions  for  the  following  reasons:  (1)  To  obtain  the 
conjoint  effect  of  two  or  more  active  substances;  (2)  to  diminish 
or  annul  undesirable  effects  produced  by  one  or  more  active  in- 
gredients; (3)  to  increase  the  solubility  or  aid  the  dissemination 
of  active  substances;  and  (4)  occasionally,  to  produce  a  new  com- 
pound. The  writing  of  a  prescription  involves  a  series  of  diffi- 
cult problems,  and,  when  first  attempted,  imposes  a  great  task  on 
the  student.  To  become  an  expert  prescription  writer  is  largely 
a  matter  of  practice.  There  are,  however,  a  few  simple,  funda- 
mental rules  which,  when  once  fixed  in  the  mind,  will  materially 
assist  in  overcoming  these  difficulties. 

"In  writing  prescriptions,  the  Latin  is  preferred:  (1)  It  is  the 
language  of  science,  and  is  understood  to  a  greater  or  less  extent 
throughout  the  civilized  world ;  in  addition,  it  is  a  dead  language, 
and  therefore  not  subject  to  the  changes  that  are  common  to  all 
living  forms  of  speech.  (2)  The  Latin  names  for  medicines  are 
distinctive,  and  very  nearly  the  same  in  all  countries.  (3)  It  is 
frequently  necessary,  and  always  advisable,  to  withhold  from  the 


64  GENEKAL   THERAPEUTICS 

patient  the  names  and  properties  of  the  medicinal  agents  adminis- 
tered. ' '     ( Remington. ) 

"What  an  insignificant  piece  of  paper  a  prescription  is;  yet  it 
may  be  the  cause  of  much  unhappiness  of  at  least  three  persons — 
the  patient,  the  pharmacist,  and  the  physician."     (Kobert.) 

The  pharmacist  who  dispenses  the  medicine  should  invariably 
retain  the  original  prescription  for  future  reference  and  as  a  rec- 
ord for  a  limited  period — say,  five  years.  That  is  for  his  own 
protection  as  well  as  for  that  of  the  prescriber  and  the  patient. 
The  medicine  prescribed  should  be  supplied  not  more  than  once 
on  the  same  prescription  in  the  following  instances: 

(a)  If  ordered  by  the  prescriber  "not  to  be  repeated,"  or 
marked  "ne  repetatur." 

(b)  If  it  contains  medicinal  substances  commonly  called  nar- 
cotic or  habit  forming  drugs. 

(c)  If  asked  for  by  a  person  known  to  be  the  original  holder. 

The  often  discussed  question  of  the  ownership  of  the  prescrip- 
tion has  given  rise  to  much  unnecessary  complexity.  As  a  matter 
of  fact,  it  is  not  a  question  of  ownership,  but  a  question  of  pos- 
session. Ownership  implies  an  intrinsic  value  in  the  thing  owned, 
while  possession  denotes  to  have  or  to  hold  as  a  property. 

A  physician 's  proscription  does  not  exhibit  the  same  character  of  pur- 
pose at  all  periods  of  its  existence,  and  therefore  the  right  to  possess  it  does 
not  always  lie  with  the  same  individual.  As  long  as  it  remains  in  the  hands 
of  the  physician  it  represents  the  embodiment  of  that  therapeutic  skill  which 
the  prescriber  has  decided  that  his  patient  stands  in  need  of,  in  the  form 
of  an  order  upon  a  licensed  druggist  to  carry  out  the  material  details  of  the 
treatment.  Up  to  this  point  it  belongs  to  the  physician.  As  soon  as  the 
physician  gives  it  to  the  patient,  the  nature  of  its  purpose  changes.  It  now 
becomes  the  embodiment  of  advice  which  the  patient  has  received  from  the 
doctor  and  to  which  he  unquestionably  has  the  right  of  possession  and  dis- 
position. He  may  avail  himself  of  the  skill  which  it  represents  by  having 
it  filled;  or  he  may  reject  it.  Whatever  disposition  he  may  make  of  it,  it 
is  certain  that  until  the  prescription  is  turned  over  to  the  druggist  for  fill- 
ing, the  right  to  possess  it  lies  with  the  patient  or  his  assigns.  The  instant 
it  is  given  to  a  druggist  to  be  filled,  the  character  of  its  purpose  undergoes 
a  further  change.  Having  received  the  treatment,  in  the  shape  of  medicine, 
for  w'hich  the  prescription  calls,  the  transaction  between  the  physician  and 
the  patient  is  completed,  and  so  far  as  the  relations  between  these  two  are 
concerned,  the  prescription  might  just  as  well  be  destroyed.  The  druggist, 
on  the  other  hand,  has  every  reason  for  possessing  it,  and  therefore  every 
right  to  its  possession  at  this  time.  It  has  ceased  to  be  an  embodiment  of 
medical    advice,    given    or    received,    and    has    taken    on    the    character    of    a 


PRESCRIPTION    WRITING  65 

vouchor.  The  law,  enacted  for  the  protection  of  both  physician  and  pa- 
tient, prohibits  the  driigoist  fiom  dispensing  tliose  drugs  unless  specifically 
ordered  to  do  so  by  the  prescriber.  The  law  may  at  any  moment  require 
the  druggist  to  show  cause  for  dispensing  the  drugs  in  question  and  unless 
he  i^osscsscs  the  physician 's  prescription,  he  is  a  convicted  criminal.  In 
fact,  the  laws  of  some  states,  and  in  case  of  dispensing  opium  or  cocain, 
etc.,  the  United  States,  lequircs  the  druggist  to  preserve  all  prescriptions 
on  file  for  several  yeais  and  to  produce  them  for  inspection  to  properly  con- 
stituted   authorities. 

A  luodern  piescription  may  be  divided  into  the  following  parts: 

1.  The  Name  of  the  Patient. — Although  frequently  omitted, 
the  name  of  the  patient  should  always  be  written  at  the  top  of 
the  prescription  in  order  to  avoid  the  possibility  of  serious  mis- 
takes.    It  should  be  written  also  on  the  label  by  the  compounder. 

2.  The  Superscription,  or  Heading. — The  symbol  I^,^  repre- 
senting the  Latin  word  recipe  (take),  is  placed  at  the  head  of 
all  Latin  prescriptions.  In  French  prescriptions,  the  letter  "P" 
{prenez,  take)   is  usually  substituted. 

3.  The  Inscription,  or  the  Names  and  Quantities  of  the 
Ingredients. — This  part  of  the  prescription  is  the  most  impor- 
tant, and  requires  the  greatest  care.  The  official  names  of  the 
drugs  should  always  be  used.  The  inscription-  often  consists  of  a 
number  of  ingredients,  and  may  be  subdivided  into:  (a)  The 
basis,  or  chief  active  ingredient;  (b)  the  adjuvant,  auxiliary,  or 
aid  to  the  basis — that  is,  to  assist  its  action;  (c)  the  corrective, 
which  is  intended  to  qualify  the  action  of  the  basis  and  adjuvant; 
(d)  the  vehicle,  diluent,  or  excipient,  which  serves  to  hold  to- 
gether, to  dilute,  or  to  give  the  whole  the  proper  consistency, 
form,  and  color. 

Each  ingredient  and  its  quantity  should  occupy  only  one  line, 
and  the  ingredients  should  follow  each  other  in  the  order  of  their 
importance.  "These  four  parts  of  a  formula,"  says  Pereira,  "are 
intended  to  accomplish  the  object  of  Asclepiades:  curare  cido,  tute 
et  jucunde,  or,  in  other  words,  to  enable  the  basis  to  cure  quickly, 
safely  and  pleasantly." 


lit  was  customary  with  the  Roman  physicians  to  prepare  a  prescription  with  a  P'ous  in- 
vocation to  Jupiter,  or  some  other  deity,  usually  expressed  by  the  Zodiacs  «'«"  -^>  t^f 
svmhol  of  the  planet  Jupiter.  The  diagonal  stroke  across  the  part  of  the  letter  K  (t*) 
heading  modern  prescriptions  is  a   relic   of  this  usage   of  the  planetary  sign. 

=  This  classic  form  of  the  inscription  was  originally  evolved  by  Dr.  Pans  from  a  qareful 
analysis  of  the  older  and  more  complex  types  of  prescriptions,  and  consisted  of  basis,  ad- 
jtivans,   corrigens,  et  excipiens. 


66  GENERAL   THERAPEUTICS 

Many  prescriptions  contain  but  one  or  two  ingredients — there 
being  no  special  use  for  a  corrective,  vehicle,  or  diluent — the  ten- 
dency of  modern  therapeutics  being  against  polypharmacy  and  in 
the  direction  of  simple  and  concentrated  remedies,  or  those  having 
positive  effects.  There  are,  however,  many  advantages  to  be  de- 
rived from  the  combination  of  ingredients  even  when  they  have 
similar  medicinal  action.  The  method  generally  followed  by  phy- 
sicians to  ascertain  the  quantity  of  each  ingredient  is,  first,  to 
write  the  names  of  the  ingredients  in  the  proper  order,  each  on  a 
separate  line,  without  affixing  the  quantities;  second,  having  de- 
cided upon  the  total  number  of  doses  that  are  to  be  given,  to  mul- 
tiply the  correct  quantity  of  a  single  dose  of  each  ingredient  by 
the  total  number  of  doses  to  be  given,  and  thus  obtain  the  re- 
quired quantity  of  each  ingredient.  Great  care  should  be  used 
in  abbreviating,  so  that  each  abbreviation  is  distinctive,  and  not 
liable  to  be  mistaken  for  an  article  not  intended  by  the  writer. 
For  example,  acid,  liydroc.  may  mean  acid,  liydrocldoric  or  acid. 
Jiydro cyanic;  liydr.  chlor.  may  mean  calomel,  corrosive  sublimate, 
or  chloral  hydrate.  The  cabalistic  characters  in  present  use  desig- 
nating the  quantities  in  a  Latin  prescription  must  be  plainly  writ- 
ten if  serious  errors  are  to  be  avoided. 

4.  The  Subscription,  or  the  Directions  to  the  Compounder. 
— Usually  no  specific  directions  are  given  to  the  compounder.  A 
single  letter,  or  two  or  three  letters,  will  serve  as  a  subscription — 
as  M.,  misce  (mix)  ;  D.S.,  detur  signetiir  (give  and  mark)  ;  M.D.S., 
misce,  da,  signa,  or  misce,  detur,  signetiir  (mix,  give,  and  mark) ; 
S.,  solve  (dissolve)  ;  F.,  fiat  (make). 

5.  The  Directions  for  the  Patient. — S.  or  Sig.,  indicating 
signatura,  precedes  the  directions  for  the  patient,  which  should 
always  be  written  in  full  and  in  plain  English.  Not  properly 
specifying  the  directions — for  example,  writing  "as  directed,"  or 
"use  as  directed,"  accompanied  by  verbal  instructions — is  a  care- 
less habit,  and  has  led  to  serious  consequences. 

6.  The  Name  or  Initials  of  the  Physician  and  Date. — The 
name  of  the  prescriber  should  always  appear  on  the  prescription, 
either  in  print  or  plainly  written. 

The  following  is  an  example  of  how  a  prescription  should  be 
written. 


PRESCRIPTION    WRITING 


67 


Name  of  Patient — 

Superscription  (Heading) — -  IJ 

Basis —  Acid,  benzoic. 

Adjuvant —  Tinct.  kramer. 


For  Mr.  Charles  Jones. 


Inscription    (Ingredicnts)- 


Subscription    (Direction)  — 


July   IG,    1916. 


3  j 

fl3  iv 

gtt.    XX 

q.  s.  ad  flS  iv 


Corrective —  01.  meiith.  pip. 
Vehicle —      Alcohol 
M. 

Sig.:     Half  a  tcaspoonful  in  a 
glass  of  water  as  a  mouth  wash. 
James  King,  D.D.S. 


Telephone  •. 

Baring  150 


Registry  No.   3675 
I.   District  .of  Pa. 


JAMES  KING,  D.D.S. 

503  Eenna  Building 

Philadelphia, Pa. 


For:  /?i^     ^lA^ayx-il^  ^^sv^-t-s^ 

Address:  / •¥- &  ^  ^(rzt-'^^tyt^t.^  ■K^i^i^.c.c^. 


9t 


7>6. 


f 


£t^' 


Hours; 
9  to  4 


Date :  S'*-^'-'^*^    '  '^ 


<^  '  (o. 


14^-OL^iyiy  cui^  CL-f    >r<.,a-<^c£,  Cc>~tC'<i.^. 


V. 


D.D.S. 


Fig.   10. 
Fac-simile    of  a   correctly   written   prescription. 


The  present  mode  of  having  prescription  blanks  printed  with 
the  full  name  and  address  of  the  prescriber,  etc.,  is  greatly  to  be 
encouraged.  In  accordance  with  the  specifications  demanded  by 
the  National  Narcotic  Law    (see   page  97)   prescriptions  calling 


68  GENERAL   THERAPEUTICS 

for  opium  or  cocain,  or  any  of  their  preparations,  salts  or  sub- 
stitutes, must  have  indicated  on  the  blank: 

1.  The  preseriber's  name  in  full; 

2.  The  location  of  his  office; 

3.  The  date  the  prescription  was  signed; 

4.  The  preseriber's  registry  number;  and 

5.  The  name  and  address  of  the  patient. 

If  simple  solutions  are  used,  prescriptions  may  be  written  so 
as  to  express  the  strength  of  the  solution  in  per  cents,  as  follows: 

R     Solutio  cocainaj  hydrochloridi  4%  flj  iv   (120  C.c.) 

In  preparing  a  percentage  solution,  it  should  be  remembered 
that  the  specific  amount  of  the  soluble  matter  is  dissolved  in  100 
parts  of  the  solution — as,  a  4  per  cent  aqueous  solution  of  cocain 
h3'drochlorid  is  composed  of  4  parts  of  cocain  hydrochlorid  and 
96  parts  of  distilled  water.  Percentage  solutions  are  best  pre- 
pared by  weighing  both  the  soluble  matter  and  the  liquid.  The 
quantity  of  soluble  substance  and  solvent  necessary  to  make  a 
specified  quantity  of  any  particular  percentage  solution  may  be 
readily  ascertained  by  the  following  rule:  Multiply  the  quantity 
of  solution  desired,  in  grams  or  grains,  by  the  number  expressing 
the  percentage,  divide  the  product  by  100,  and  the  quotient  will 
indicate  the  quantity  of  soluble  substance  necessary;  subtract  this 
from  the  total  quantity  of  solution  desired,  and  the  remainder 
will  indicate  the  necessary  quantity  of  solvent. 

Metric  Prescription  Writing. 

Metric  prescription  writing  is  universally  employed  in  all  coun- 
tries except  in  those  inhabited  by  English-speaking  communities. 
In  the  United  States  and  England  it  is  at  present  practiced  only 
to  a  limited  extent,  although  strenuous  efforts  are  made  to  popu- 
larize this  method  by  teaching  it  in  the  various  medical,  dental 
and  veterinary  schools.  In  continental  Europe  all  ingredients  en- 
tering into  a  prescription  are  weighed,  no  measures  of  capacity, 
except  drops,  being  emploj^ed.  The  unit  of  weight  is  the  gram. 
In  the  United  States  two  methods  of  expressing  the  quantities  are 
in  vogue — one  is  the  volumetric  method,  which,  following  the 
usual  American  practice,  measures  the  liquids,  and  the  other  is 
the  European  or  gravimetric  method.  The  former  is  preferred 
by  many.    The  unit  of  measure  is  the  cubic  centimeter    (abbrevi- 


PRESCRIPTION    \VRITING  69 

ated  C.c),  which  is  the  equivalent  of  one  gram  of  distilled  water 
at  4°  C.  The  gravimetric  method — weighing  of  all  ingredients — 
is  by  far  the  better  method,  as  under  all  conditions  (temperature, 
specific  gravity,  etc.)  it  will  furnish  the  exact  quantity  as  specified 
in  the  prescription.     An  example  will  illustrate  the  two  methods: 

Volumetric.  t  Gravimetric. 

Gm.  vel  C.c. 


Acid,  benzoic    4 

Tinct.  kramer 15 

01.  menth.  pip 1 

Alcohol q.  s.  ad  120 


Acid,  benzoic   4.0 

Tinct.  kramer 15.0 

01.  menth.  pip 1.5 

Alcohol    q.  s.   ad  120.0 


Grammatical  Construction  of  a  Latin  Prescription. 

The  advantage  of  writing  a  prescription  in  Latin  has  been 
referred  to  on  page  63.  To  correctly  construct  the  terminology 
of  a  prescription  requires  a  fundamental  knowledge  of  Latin  gram- 
mar. In  writing  the  heading  of  the  prescription,  I> — recipe  (take) 
[thou] — the  imperative  singular  is  employed,  as  it  refers  to  the 
quantity  to  be  taken.  The  latter  is,  in  consequence,  placed  in  the 
accusative : 

Ji.      drachmam  unani. 

Take  [thou] one  dram. 

The  quantity  expressed  refers  to  the  name  of  the  drug,  and  the 
latter,  according  to  rule,  is  placed  in  the  genitive: 

R     Magnesii  sulphatis  drachmam  unam. 

Take  [thou]  one  dram  of  sulphate  of  magnesia. 

When  ''ad"  follows  the  vehicle,  the  latter  is  placed  in  the  ac- 
cusative : 

IJ     Magnesii  sulphatis  drachman  unam. 

Aquam  ad  fluid  unciam  unam. 

Take   [thou]    one  dram  of  sulphate  of  magnesia    [and]    enough 

water  to  make  a  fluidounce. 

Owing  to  common  practice,  the  last  syllable  of  the  Latin  words, 
which  varies  with  the  case,  is  usually  omitted,  but,  to  correctly 


70  GENERAL   THERAPEUTICS 

interpret  the  Latin  words,  the  ease  endings  must  be  remembered. 
The  following  simple  rules  will  serve  to  call  to  mind  the  above 
mentioned  principles: 

Rule  I.     The  noun  expressing  the  name  of  the  medicine  is  put 
in  the  genitive  case  when  the  quantity  of  it  to  be  used  is  expressed. 

Rule  II. — If  no  quantity  is  expressed,  but  only  a  numeral  ad- 
jective follows,  the  noun  is  put  in  the  accusative. 

Rule  III.    The  quantity  is  put  in  the  accusative  case,  governed 
by  the  imperative  Recipe. 

Rule  IV.     Adjectives  agree  with  these  nouns  in  gender,  num- 
ber, and  case. 

Latin  Genitive  Case  Endings. 

NOMINATIVE.      GENITIVE.  EXCEPTIONS. 

-a -ae  . . .  .Cataplasma,  enema,  physostigma,  aspidospenna,  and 

gargarisma  end  in  -atis;  folia  (pi.),  foliorum;  coca 
is  unchanged,  though  cocae  is  used  by  some. 

-us,  -um,  -os...-i    Rhus,  rhois;   flos,  floris;   bos,  bovis;  limon,  limonis; 

erigeron,  erigerontis;  quercus,  cornus,  fructus, 
spiritus,  haustus,  and  potus  are  unchanged. 

-as -atis    .  .Asclepias,  adis;  mas,  maris;  sassafras  is  unchanged. 

-is   -idis    .  .Pulvis,  -eris;  arsenis,  phosphis,  sulphis,  and  all  salts 

ending  in  -is  take  the  ending  -itis;  berberis,  can- 
nabis, digitalis,  hydrastis,  and  sinapis  are  un- 
changed. 

-0 -onis    .  Mucilago,  ustilago,  and  solidago  end   in  -inis;   con- 

durango,  kino,  sago,  and  matico  are  unchanged. 

-1  -lis  . . .  .Fel,  fellis;  mel,  mellis;  sumbul,  sumbuli. 

-en     -inis    ..Azedarach,    buchu,    catechu,    curare,    jaborandi,    and 

amyl  are  iinchanged,  though  amylis  is  sometimes 
used. 

-ps    -pis  . . . 

-rs -rtis     . . 

-r     -ris    . . . 

-X    -cis    . . . 


Terms  Used  in  Prescription  Writing. 

The   more   important   abbreviations   and   Latin   terms   used   in 
writing  prescriptions : 


PRESCRIPTION    WRITING 


71 


aa,    ana of  each. 

ad   to,  up  to. 

adde   add  to  it. 

ad  lib.,  ad  libitum. at  pleasure. 

bis    twice, 

b.  i.  d.,  bis  in  die. twice  daily. 

caute cautiously, 

cochleare    a  spoonful. 

cochleare  mag- 
num     a  tablespoonful. 

cochleare    parvum.a  teaspoonful. 

coctio    boiling. 

cola    ..strain. 

contusus bruises. 

cujus    of  which,  of  any. 

cum with. 

da,  detur give. 

decanta    pour  off. 

d.  t.  d.,  dentur  tales 

doses let    such    doses    be 

given, 

dilue dilute. 

d.  in  p.  seq.,  divide 
in    partes    sequa- 

los let  it  be  divided  in 

equal  parts. 


ejusdem   of  the  same. 

et    and. 

f.,  fiat,  fiant let  it  be  made. 

filtra  filter. 

idem   the  same. 

inter  between. 

misce    mix. 

non   not, 

omni  hora every  hjur. 

pro    for. 

p.    r.    n.,    pro    re 

nata    occasionally. 

q.    s.,    quantum 

satis    as  much  as  is  suf- 
ficient. 

icccns fresh. 

rcpetatur let  it  be  repeated. 

s.  a.,  secundum 

artem    according  to  art. 

scmel    once. 

signa    mark. 

sine without. 

solve  dissolve. 

talis    such,  like  this. 

t.  i.  d.,  ter  in  die.. three  times  daily, 
tore rub. 


Reference  Abbreviations. 


U.S.  p.  .United  States  Pharmacopeia. 
B.  P British  Pharmacopeia. 


P.   G German   Plitirmacopeia. 

N.  F National  Formulary. 


Signs  and  Numerals  Used  in  Prescription  Writing. 

li recipe take. 

lb libra a  pound, 

5 uncia    an  ounce, 

3 drachma a  dram, 

3 scrupulus a  scruple, 

gr granum   a  grain. 

C congius    a  gallon. 

0 octarius a  pint. 

flS fluiduncia  a  fluidounce. 

fl3 fluidrachma    a  fluidram. 

Ttl, minim    a  drop. 

gtt gutta a  drop. 

ss semis  half. 


72  GENKRAL    THERAPEUTICS 

The  Use  of  liatin  Numerals. 

All  Latin  numbers  are  expressed  by  one,  or  a  combination  of 
two  or  more,  of  the  following  letters:  I,  V,  X,  L,  C,  D,  and  M. 
I  means  1 ;  V,  5;  X,  10;  L,  50;  C,  100;  D,  500;  and  M,  1000. 
These  should  be  written  together  as  capital  letters,  but  in  prescrip- 
tions we  find  them  usually  written  as  small  letters,  or  in  print  as 
"lower  case"  letters,  and  it  is  customary  to  write  a  single  "i, "  or 
the  final  "i"  when  several  numeral  letters  are  used  together,  as  a 
small  "j."    The  letters  are  combined  thus: 


I  1 

II   2 

III    .3 

IV     4 

V     5 

VI 6 

VII 7 

VIII  8 

IX 9 

X    10 

XI     11 


XX   20 

XL    40 

L 50 

LX    60 

XC    90 

C  100 

CC     200 

D 500 

DC    600 

M    1000 

MCMXVII    1917 


Estimation  of  Quantities. 

The  estimation  of  the  quantity  of  each  ingredient  entering  into 
a  compound  prescription  is  usually  ascertained  after  the  various 
drugs  have  been  written  in  their  order,  beginning  with  the  solids. 
The  amount  of  the  Avhole  mixture,  powder,  etc.,  is  Avritten  after 
the  last  ingredient,  which  is  usually  the  diluent,  and  the  quantity 
of  each  drug  is  ascertained  hy  multiplying  the  single  dose  hy  the 
nmnher  of  doses  represented  in  the  ivhole  prescription.  The  fol- 
lowing may  serve  as  an  example: 

It  is  desired  to  write  a  prescription  for  a  four-ounce  mixture, 
with  a  dram  (a  teaspoonful)  at  a  dose,  each  dose  to  represent  two 
grains  of  quinin  sulphate,  one-eighth  of  a  grain  of  codein  phos- 
phate, half  a  dram  of  syrup  of  licorice,  and  water  enough  to  make 
a  teaspoonful.  As  4  ounces  are  32  drams,  the  prescription  will 
read  as  follows: 

B     Quinin  sulphate  2  gr.       x  32  z=  3  j 

Codein  phosphate  %  gr.       x  32  =  gr.  iv 

Syrup  of  licorice  V^  dram  x  32  =  fl5  ij 

Water  enough  to  make  flS  iv 

M. 

Sig. :     Teaspoonful  every  two  hours. 


ESTIMATION    OF    QUANTITIES 


73 


To  assist  the  compounder  in  filling  the  prescription,  it  is  cus- 
tomary to  express  the  multiples  of  grains,  when  they  closely  ap- 
proximate half  a  dram  or  more,  in  round  numbers.  In  the  above 
ease,  to  be  exact,  64  grains  of  quinin  sulphate  are  called  for,  but, 
following  the  rule,  one  dram  is  written. 

The  bottles  used  in  the  United  States  and  England  have  a 
capacity  of  one,  two,  and  four  fluidrams,  and  one,  two,  three, 
four,  six,  eight,  twelve,  sixteen,  and  thirty-two  fluidounces,  or  their 
relative  metric  equivalents  expressed  in  cubic  centimeters  (C.c). 
It  is  good  practice,  in  prescription  writing,  to  conform  the  quan- 
tity of  the  mixture  to  the  above  sizes  of  bottles.  The  quantity  of 
medicine  ordered  should  last  from  two  to  three  days,  except  in  the 
treatment  of  chronic  diseases.  Mouth  washes  may  be  ordered  in 
four  to  sixteen-ounce  quantities.  In  meas- 
uring out  the  medicine  to  the  patient,  a 
graduated  medicine  glass  is  far  preferable 
to  the  domestic  measures,  as  the  latter  vary 
considerably.  The  domestic  teaspoonful 
varies  greatly  in  size,  and  Wilbert  there- 
fore suggests  that  a  teaspoonful  should  be 
represented  by  li^  drams,  or  5  cubic  cen- 
timeters. Drops  should  always  be  meas- 
ured with  a  medicine  dropper  or  dispensed 
in  a  special  drop  bottle.  The  size  of  the 
individual  drops  and  their  number  present 
in  a  given  amount  of  fluid  varies  greatly; 

it  depends  largely  on  the  specific  gravity,  consistency,  surface  ten- 
sion and  temperature  of  the  liquid,  on  the  lip  of  the  bottle  from 
which  they  are  dropped,  etc.  As  stated  above,  dropping  bottles  are 
to  be  recommended  for  measuring  out  liquids  by  the  drop,  but  they 
have  to  be  individually  standardized  before  they  are  employed. 

Dr.  Seaman  recommended  to  the  Committee  on  Revision  of  the 
United  States  Pharmacopeia  the  following  method  of  accurate 
drop  measure :  ' '  An  official  medicine  dropper  has  its  delivery  end 
three  millimeters  in  external  diameter,  and  adapted  to  deliver  20 
drops  of  distilled  water  to  a  gram  at  15°  C." 

Powders  are  usually  prescribed  to  weigh  from  three  to  ten  grains; 
if  they  contain  nauseating  tasting  drugs,  they  should  be  dispensed 


Fig.   11. 

Graduated    medicine    glass. 


74  GENERAL   THERAPEUTICS 

in  capsules  or  wafers.  Pills  usually  weigh  from  one  to  three 
grains,  and  those  that  weigh  less  than  a  grain  are  known  as  gran- 
ules.    Salves  are  prescribed  in  one-half  to  two-ounce  quantities. 


Fig.  12. 
Medicine  dropper. 

Oils,  balsams,  oleoresins,  and  similar  liquids,  if  prepared  in  drop 
doses,  are  best  dispensed  in  soft  or  hard  gelatin  capsules.  Solid 
and  semi-solid  dentifrices — such  as  powders,  pastes,  and  soaps — 
are  usually  dispensed  in  specially  prepared  containers,  while  bot- 
tles containing  mouth  washes  are  often  provided  with  sprinkler 
tops. 

INCOMPATIBILITIES. 

Incompatibilities  may  be  defined  as  conditions  produced  by 
bringing  substances  together  which  result  in  chemic  decomposi- 
tion, pharmaceutic  dissociation,  or  therapeutic  opposition.  (Rem- 
ington. ) 

In  writing  a  prescription  which  contains  more  than  one  drug, 
one  or  all  of  the  above  possibilities  may  be  the  result  of  the  mix- 
ture, unless  the  prescriber  exercises  extreme  care  in  considering 
the  physical,  chemic,  and  phj-siologic  properties  of  the  ingredi- 
ents entering  into  the  compound.  Never  prescribe  more  than  one 
drug  at  a  time,  if  the  one  remedy  will  serve  the  purpose  for  which 
it  is  intended! 

1,  Chemic  Incompatibility. — It  may  result  in  (a)  explosion 
in  mixing  chlorates  or  permanganates  with  readily  oxidizable  sub- 
stances (all  organic  substances — sulphur,  etc.)  ;  (b)  precipitation 
— in  general,  inorganic  bases  or  their  salts  precipitate  inorganic 
acids,  and  salts  of  metals  precipitate  organic  substances;  (c)  pro- 
duction of  a  substance  with  undesirable  properties — iodids,  bro- 
mids,  iodates,  bromates,  and  chlorates  with  strong  mineral  acids 
or  strong  oxidizing  agents. 

2.  Pharmaceutic  Incompatibility. —  (a)  Alcoliol  should  not 
be  added  to  solutions  of  acacia,  gelatin,  and  proteins,  or  to  emul- 
sions and  strong  salt  solutions;  (b)  water  should  not  be  added  to 


INCOMPATIBILITIES  75 

alcoholic  liquids  in  general  (tinctures,  spirits,  fluid  extracts)  ; 
(c)  certain  chemicals,  like  camphor  or  antipyrin,  when  mixed 
with  phenol,  thymol,  cocain,  salol,  resorcinol,  etc.,  produce  oily 
liquids;  (d)  cocain  and  borax  form  an  insoluble  borate  of  cocain. 

3.  Therapeutic  Incompatibility. — As  a  rule,  a  drug  is  in- 
compatible with  its  antidotes — as  pilocarpin  and  atropin;  cocain 
and  morphin;  strychnin  and  alcohol,  etc. 

As  it  is  impossible  to  consider  in  detail  all  the  incompatibilities, 
only  a  few  of  the  more  important  ones  will  be  enumerated : 

An  acid  should  not  be  combined  with  an  alkali. 

Most  of  the  acids  precipitate  albumin. 

Arsenic  trioxid  is  precipitated  by  salts  of  iron  and  magnesia, 
which  are  its  official  antidote. 

Phenol  forms  a  phenolsulphonate  when  added  to  a  soluble 
sulphate. 

Salicylic  acid  is  incompatible  with  salts  of  iron. 

Alkalies  should  not  be  combined  with  alkaloids. 

Alkaloids  and  metallic  salts  are  incompatible  with  tannic  acid 
or  substances  containing  tannin,  and  with  alkalies  or  their  salts. 

Alcoholic  fluid  extracts  are  precipitated  by  water  or  aqueous 
liquids. 

lodin  or  iodids  should  not  be  given  with  alkalies. 

Oils,  volatile  and  fixed,  resins,  oleoresins,  resinoids,  and  balsams 
are  precipitated  by  water. 

Sugar  forms  an  explosive  with  sulphuric  acid. 

Corrosive  sublimate,  silver  nitrate,  potassium  iodid,  and  the 
salts  of  lead  should  preferably  be  prescribed  alone.  Corrosive 
sublimate  is  frequently  prescribed  in  combination  with  potassium 
iodid,  when  a  precipitate  is  formed  which  is  readily  dissolved. 
Silver  nitrate  and  lead  acetate  are  frequently  prescribed  with  the 
extracts  of  opium  and  hyoscyamus.  Substances  containing  loosely 
combined  oxygen — as  chromic  acid,  concentrated  nitric  acid,  per- 
manganates, chlorates,  etc. — should  not  be  combined  with  easily 
oxidizable  substances  (as  all  organic  substances — tannic  acid,  sul- 
phur, sulphids,  sulphites,  iodin,  iodids,  phosphorus,  phosphites, 
and  reduced  iron — which  form  highly  explosive  compounds). 

Vegetable  astringents  containing  tannic  acid  should  not  be 
mixed  with  iron,  as  they  form  a  tannate  of  iron  (ink). 

Alcohol  and  alcoholic  liquids  are  incompatible  with  mucilages. 


76  GENERAL   THERAPEUTICS 

Examples  of  Incompatibility. 

IJ     Cocainse  hydiochlor.  gr.  v 

Sod.  borat.  gr.  x 

Aq.  ad  flS  j 

M. 

Sig. :     Use  as  a  paint. 

An  insoluble  cocain  borate  is  formed. 

IJ     Sod.  borat.  3  vj 

Mucilag.  acac.  flS  j 

Aq.  menth.  pip.  ad  flj  viij 

M. 

Sig.:     Tablespoonful  three  times  daily. 

The  borax  will  be  precipitated  by  the  mucilage  in  translucent 
flocculeiit  masses. 

IJ     Pot.  permaugan.  3  j 

Aq.  hydrogen,  dioxid.  flj  ij 

Aq.  ad  flS  viij 

M. 

Sig.:     Antiseptic  solution. 

The  portassium  permanganate  is  decomposed  by  the  solution  of 
hydrogen  dioxid. 


I^ 

Pot.  permangan. 

5  j 

Liq.  formaldehyd. 

flg  iij 

Aq. 

ad  flS  viij 

M. 

Sig.:     For  disin 

fecting  purposes. 

A  violent  reaction  between  the  potassium  permanganate  and 
the  solution  of  fonnaldehyd  results,  setting  free  vapors  of  formal- 
dehyd. 

I^    Phenol. 

Camphoraj  aa  3  ij 

M.  f.  plv.  No.  j. 
Sig. :     Dissolve  in  a  quart  of  water. 

Phenol  and  camphor  liquefy  when  triturated  together,  and  very 
little  of  the  camphor  will  dissolve  in  the  water. 

IJ     Magnes.  oxid.  3  ij 

Aq.  menth.  pip.  flS  iij 

M.    Shake  the  bottle. 
Sig.:     Tablespoonful  three  times  daily. 


INCOMPATIBILITIES  77 

Tlic  nuigiicsia  settles  to  a  solid  mass,  which  cannot  be  readily 
di,sinto«rated  by  shaking. 


IJ     Liq.  plumbi  subacet. 

fl5  iv 

Tinct.  opii 

fl5  j 

Aq. 

ad  flS  xvj 

M. 

Sig.:     Use  externally. 

This  is  the  much  used  lead  water  and  laudanum.  The  alkaloids 
of  opium  are  precipitated  by  the  solution  of  lead  subacetate,  and, 
besides,  opium  does  not  exert  any  local  action. 


IJ     Sod.  borat. 

gr.  iij 

Zinc  sulphat. 

gr.  iv 

Aq.  destill. 

m  j 

M. 

Sig. :     Drop  into  the  eye. 

An  insoluble  zinc  borate  is  formed. 

I^     Argenti  nitrat.  3  ij 

Aq.  rosse  fl5  j 

M. 

Sig. :     Concentrated  silver  nitrate  solution  for  dental  pur- 
poses. 

Most  of  the  silver  niti-ate  is  precipitated  as  a  black  powder  by 
the  oil  of  rose  and  the  impurities  of  the  rose  Avater.  Only  distilled 
water  should  be  used  in  making  silver  nitrate  solutions. 


Pot.  chlorat. 

3  j 

Acid,  tannic. 

3  ss 

Amyl. 

ad  S  ij 

M.  f.  plv. 

Sig.:     Use 

as 

a 

dusting 

powder. 

An  explosive  compound  results. 

B     Phenol. 

Thymol.  fifi  3  ij 

M.  f.  plv.  No.  ij. 

Sig.:     Dissolve  in  one  ounce  of  alcohol,  and  use   for  the 
treatment  of  putrescent  root  canals. 

Phenol  and  thymol  liquefy  -when  triturated  together. 


78  GENERAL   THERAPEUTICS 

I^     Chloral  hydrat. 

Sulphonal.  aa  gr.  xv 

M.  f.  plv.  No.  vj. 
Sig. :     One  powder  every  other  evening. 

When  triturated  together  the  two  drugs  form  a  soft,  pasty  mass. 


Coloring  and  Flavoring  Agents. 

To  facilitate  the  administration  of  medicines  and  their  psycho- 
logic effect,  in  some  cases  at  least,  coloring  and  flavoring  agents 
are  needful  aids. 

Coloring  Agents. — About  10  drops  of  any  of  the  following 
liquids  will  color  four  ounces  of  a  colorless  mixture:  Red:  Com- 
pound tincture  of  lavender,  compound  tincture  of  cardamom; 
Brown:  liquid  caramel;  Yellow:  tincture  of  safron,  tincture  of 
tumeric. 

The  following  syrups  may  also  be  employed  for  the  same  pur- 
pose, although  larger  quantities  have  to  be  used:  Simple  Syrup 
— colorless;  Syrup  of  Orange — golden  yellow;  Syrup  of  Wild 
Cherry — cherry  red  (for  acid  mixtures  only)  ;  Syrup  of  Tolu — 
light  yellow;  Syrup  of  Lemon — light  yellow;  Syrup  of  Licorice 
root — brown;  Syrup  of  Rhubarb — brown-red  (for  alkaline  mix- 
tures only)  ;  Syrup  of  Ginger — light  brown ;  Syrup  of  Raspberry 
— rose  red  (for  acid  mixtures  only)  ;  Syrup  of  Senega — light  brown ; 
Syrup  of  Ipecac — faintly  yellow   (for  alkaline  mixtures  only). 

Flavoring  Agents. — Syrups  are  the  usual  flavoring  agents  em- 
ployed. They  may  be  given  undiluted  to  children,  unless  the 
existing  diseases  should  contraindicate  their  administration.  Mix- 
tures intended  for  adults  should  not  contain  more  than  25  per 
cent  of  syrup,  except  when  bitter  medicines  are  prescribed. 

Flavoring  Agents  for  Acid  Mixtures. — Simple  syrups  or  the 
syrups  of  ginger,  lemon,  orange,  raspberry,  tolu  or  wild  cherry. 

Flavoring  Agents  for  Bitter  Mixtures. — The  syrups  of  orange, 
ginger,  tolu,  etc. 

For  Quinin  Mixtures. — The  syrup  of  yerba  santa  or  of  licorice 
root. 

For  Ammonium  CMorid  Solution. — Syrup  of  licorice  root. 

For  Potassium  lodid  Solution. — Milk,  peppermint  water. 


WEIGHTS    AND    MEASURES  79 

For  Chloral  Hydrate  Solution. — The  syrups  of  licorice  root, 
orange,  tolu,  etc. 

For  Cod  Liver  Oil. — Oil  of  peppermint. 

For  Caster  Oil. — Oil  of  peppermint,  syrup  of  orange,  etc. 

WEIGHTS  AND  MEASURES. 

The  system  of  weights  and  measures  as  used  in  the  United 
States  was  standardized  in  1836,  when  the  then  Secretary  of  the 
Treasury  was  authorized  by  Congress  to  furnish  each  state  of  the 
Union  with  a  complete  set  of  revised  standards  for  weights,  liquid 
measures,  and  measures  of  length.  These  various  methods  of 
weights  and  measures  are  quite  confusing  when  an  examination  of 
their  comparative  units  is  made — that  is,  it  is  perplexing  to  find 
that  a  pound  is  not  a  pint,  an  ounce  does  not  equal  a  fluidounce, 
and  a  drop  is  neither  a  grain  nor  a  minim. 

The  United  States  National  Prototype  Standards,  from  which 
all  weights  and  measures  now  used  in  this  country  are  derived, 
are  the  meter  and  the  kilogram,  and  they  are  preserved  in  the 
custody  of  the  National  Bureau  of  Standards  at  Washington.  The 
United  States  meter  and  kilogram  are  identical  with  the  interna- 
tional standards  of  the  same  capacity. 

The  United  States  standards  of  weights  and  measures  are: 

The  apothecaries'  or  troy  ounce  .=  480  grains. 

The  commercial  or  avoirdupois  ounce  =  437.5  grains. 
The   apothecaries'   fluidounce    (identical 

with  the  fluidounce  of  the  liquid  gallon)  =  480  minims. 

The  weights  and  measures  used  in  the  British  Pharmacopeia 
are  the  Imperial  weights  and  measures,  legal  for  commercial  pur- 
poses in  the  British  Empire.  The  English  apothecaries'  weights 
are  the  same  as  those  used  in  the  United  States. 

Apothecaries'  Weight. 


Pound. 

lb  1 

Troy  ounces. 
=             12 

Drams. 
=             96 

Scruples. 
=             288 

— 

Troy  grains. 
5760 

S  1 

=               8 

=               24 

=:z 

480 

3  1 

=                 3 
3   1 

^IZ 

60 
gr.  20 

Troy  Weight. 

Pound, 
lb   1 

Troy  ounces. 
=                  12                  = 

Pennyweights. 
240 



Troy  grains. 
5760 

5  1 

= 

20 
dwt.  1 

=: 

480 
gr.  24 

80  GENERAL   THERAPEUTICS 

Avoirdupois  Weight. 


Pound. 

lb  1 

— 

Ounces. 
16 

— 

Drams. 
256 

07..    1 

= 

16 
dr.  1 

Troy  grains. 
7000. 

437.5 

gr.  27.34375 


Relative  Value  of  Troy  and  Avoirdupois  Pounds. 

troy  pound  =:  0.822857  avoirdupoi 

avoirdupois  pound  =  1.215277  troy  pounc 

Apothecaries'  or  Wine  Measure  (United  States). 


Gallon. 
Cong.  1 

Pints. 

fluidounces.          Fluidranis. 
128        =:        1024        = 

Minims. 
61440        = 

Cubic  inches. 
231 

0  1        == 

16        ==          128        = 

7680        = 

28.875 

n  1       =            8       = 

480        = 

1.8047 

fl3  1        = 

ni  60       = 

.2256 

Liquid  Measure. 

I  gallon 

= 

4  quarts.               1  pint 

=             4 

gills. 

1  quart 

= 

2  pints.             j    1  gill 

=             4 

fluidounccs. 

Imperial 

Measure  (British  Pharmacopeia). 

Gallon. 

1 

Pints. 
=                 8 

I'liiidounces.                       Fli 
=             160             — 

jidranis. 

1280             = 

Minims. 
76800 

1 

==              20            = 

160             = 

9600 

" 

1            = 

8             = 

480 

- 

1             = 

60 

The  Metric  System.^ 
The  metric  or  decimal  system  of  weights  and  measures  origi- 
nated with  Prince  de  Talleyrand,  bishop  of  Autun,  in  1790.  Its 
almost  universal  adoption  by  civilized  nations,  its  legality  (though 
not  compulsion)  in  England  and  the  United  States,  and  its  adop- 
tion by  the  United  States  Pharmacopeia  of  1890  demand  that  it 
should  be  understood  by  the  progressive  practicing  physician.  Ex- 
cept in  the  English-speaking  world,  it  is  the  only  system  of  weights 
and  measures  used  for  governmental,  statistical,  and  scientific  pur- 
poses. It  is  based  upon  the  decimal  system — that  is,  the  denomi- 
nations increase  by  tens  and  decrease  by  tenths.  The  starting 
point  is  the  unit  of  linear  measure,  the  meter,  which  represents 
one-ten-millionth  part  of  the  polar  quadrant  of  the  earth — that  is, 
the  distance  from  the  equator  to  the  poles — and  is  equivalent  to 
39.37  English  inches.     The  gram   (Gm.)    is  the  unit  of  weight; 


'  The  metric  system  was  legalized  in  Great  Britain  in  1864,  and  in  the  United  States 
by  act  of  Congress  in  1866.  It  is  now  required  in  medical  work  of  the  Army  and  Navy 
Departments  and  in  the  Public  Health  Service. 


WEIGHTS    AND    MEASURES  8l 

the  liter,  of  capacity  (although  the  cubic  centimeter  is  oftenev 
preferably  used)  ;  the  are,  of  surface  measure.  The  denomina- 
tions representing  the  subdivisions  of  any  unit  are  expressed  by 
prefixing  the  Latin  numerals  deci,  cenii,  and  milli  to  the  unit — 
meaning  respectively  one-tenth,  one-hundredth,  and  one-thou- 
sandth; the  multiples  arc  expressed  by  pi-efixing  the  Greek  num- 
erals deka,  liecto,  Jcilo,  and  myria — meaning  ten,  hundred,  thou- 
sand, and  ten  thousand. 

The  gram  is  derived  as  follows:  The  meter  is  divided  into  one 
nundred  equal  parts,  called  centimeters.  On  one  centimeter  as 
a  base  a  cube  is  erected,  having  for  its  three  dimensions  one  centi- 
meter (Cm.)  each.  The  contents  of  this  cube  Avill  be  one  cubic 
centimeter  (C.c),  measuring  one  milliliter.  This  quantity  of  dis- 
tilled water  at  its  maximum  density  (39.2°  F.,  4°  C.)  and  30 
inches  barometric  pressure  weighs  one  gram,  or  15.432  grains. 

The  liter  is  derived  as  follows:  The  meter  is  divided  into  ten 
equal  parts,  called  decimeters.  On  one  decimeter  as  a  base  a 
cube  is  erected,  having  for  its  three  dimensions  one  decimeter 
(dm.)  each.  The  contents  of  this  cube  will  be  one  cubic  decimeter 
(dm.^),  the  capacity  of  Avhich  is  one  liter,  equivalent  to  1,000 
cubic  centimeters,  or  33.81  fluidounces,  or  2.113  pints.  One  liter 
of  distilled  water  at  4°  C.  and  30  inches  barometric  pressure  weighs 
1,000  grams,  or  1  kilogram,  or  2.2  pounds  avoirdupois,  or  15,432 
grains. 

The  present  U.  S.  Pharmacopeia  (IX.  revision)  has  replaced  the 
term  cubic  centimeter  by  the  word  7nil  (the  first  three  letters  of  the 
word  milliliter),  claiming  that  the  term  cubic  centimeter  is  a  mis- 
nomer. The  U.  S.  Bureau  of  Standards  has  declared  that  there  is 
a  slight  difference  between  the  thousandth  part  of  a  liter  and  the 
cubic  centimeter. 

Metric  Weights  and  Measures. 

The  meter,  or  unit  of  length,  =  39.37043  inches. 

Tlie  liter,  or  unit  of  capacity,  =  33.814  fluidounces  (U.  S.). 

Tlic  gram,  or  unit  of  weight,  =  15.432348  ti'oy  grains. 

Metric  Measures  of  Length. 

Knglish  inches.  English  inches. 

Millimeter  (mm.)           =             .03937       Decimeter  (dm.)  =           3.93704 

Centimeter  (cm.)           =            .39370      Meter   (m.)  =         39.37043 
Kilometer  =  39370.43  English  inches. 


82 


GENERAL   THERAPEUTICS 


Metric  Measures  of  Capacity. 


English  cubic  inchps. 

Milliliter  (Cc.)  =  .06102       Deciliter  (dl.) 

Centiliter  (cl.)  =  .61028       Liter   (L.) 

Hectoliter  ^  G102.8  English  cubic  inches. 


English  cubic  inches. 
=  6.10280 

=  61.02800 


Metric  Measures  of  Weight. 


Troy  grains. 

Troy  grains. 

Milligram  (mg.) 

= 

.0154 

Decigram  (dg.) 

= 

1.5432 

Centigram  (eg.) 

= 

.1543 

Gram  (Gm.) 

= 

15.4324 

Kilogram  =  15432.34  troy  grains. 


Apothecaries'  Weight  and  Metric  Equivalents. 


Vloo  g 

%4 
%0 
'/40 

•/ic 
Vo 

\i 

% 

1  gra 

2  gra 
3 
4 
5 
6 
8 

10 
12 


0.0006 

grams. 

15 

grains 

= 

0.97  gra 

0.001 

<  ( 

15.4 

= 

1.         " 

0.0013 

11 

20 

= 

1.3       " 

0.0016 

1 1 

24 

= 

1.55     " 

0.002 

<< 

30 

= 

1.94     " 

0.003 

<( 

40 

nz 

2.6       " 

0.004 

<  < 

45 

= 

2.92     " 

0.005 

(( 

50 

= 

3.23     " 

0.006 

<( 

60 

"    (1 

dram  ) 

= 

3.89     " 

0.008 

tt 

11/^ 

drams 

= 

5.58     " 

0.011 

n 

1% 

zzz 

6.81     " 

0.012 

it 

2 

— 

7.78     " 

0.015 

1 1 

2^ 

= 

9.72     " 

0.022 

ti 

3 

= 

11.65     " 

0.032 

(( 

4 

=: 

15.55     " 

0.048 

(( 

5 

=z 

19.43     " 

0.065 

tt 

6 

= 

23.3       " 

0.13 

It 

1  ounce  (480  grains 

)  = 

31.1       " 

0.2 

tt 

2  ounces 

= 

62.2       " 

0.26 

tt 

3 

= 

93.3       " 

0.32 

tt 

4 

^ 

124.4       " 

0.39 

tt 

6 

= 

186.6       " 

0.52 

tt 

8 

= 

248.8       " 

0.65 

tt 

10 

= 

311.         " 

0.78 

tt 

12 

= 

373.2       " 

WEIUHTS   AND   MEASURES 


83 


Apothecaries'  Measure  and  Metric  Equivalents. 


1  mi 

2  m 
3 
4 
5 


9 
10 
15 
20 
25 
30 
40 
45 
50 


mm 

nims 


0.06  C.c. 

60  minims  (lfluidram)=z 

3.70  C.c 

0.12    " 

ly* 

fluidrams 

= 

4.65    " 

0.18    '' 

11/2 

= 

5.60    " 

0.24    " 

1% 

= 

6.50    " 

0.30    " 

2 

= 

7.50    " 

0.36    " 

3 

^r 

11.25    " 

0.42    " 

4 

^^ 

15.00    " 

0.50    " 

8 

"  (Ifluidoz 

)  = 

30.00    " 

0.55    " 

(more  exactly) 

= 

29.57    " 

0.60    " 

2  fluidounces 

= 

59.15    " 

0.92    " 

3 

= 

88.72    " 

1.25    " 

4 

= 

118.29    " 

1.54    " 

8 

= 

236.59    " 

1.90    " 

16 

"    (Ipint) 

r=: 

473.18    " 

2.50    " 

32 

= 

946.36    " 

2.80    " 

128 

"    (1  gallon 

)  — 

3785.43    " 

3.10    " 

Weight  Equivalents. 

To  convert  grains  into  grams  multiply  by 0.065 

To  convert  grams  into   grains  multiply  by 15.5 

To  convert  drams  into   grams  multiply   by 3.9 

To  convert  ounces   (avoirdupois)   into  grams  multiply  by 28.4 

To  convert  pounds   (avoirdupois)   into  grams  multiply  by 453.6 


Measure  Equivalents. 

To  convert  cubic  centimeters  into  grains  multiply  by 15.5 

To  convert  cubic  centimeters  into  drams  multiply  by 0.26 

To  convert  cubic  centimeters  into  ounces  (avoirdupois)   multiply  by. .  9.03 

To  convert  pints  into  cubic  centimeters  multiply  by 473. 

To  convert  liters  into  ounces   (avoirdupois)   multiply  by 35.3 

To  convert  gallons  into  liters  multiply  by 3.8 


Approximate  Measures. 


A  drop  equals  roughly      1  minim. 
A  teaspoonful  =     1  fluidram. 

A  dessertspoonful      =    2  fluidrams. 
A  tablespoonful         =  14  fluidounce. 


A  wineglassful 
A  teacupful 
A  tumberful 
A  handful 


=  2  fluidounces. 

=  4  fluidounces. 

=  8  fluidounces. 

=  4  ounces. 


84 


tifeNfiRAL   TtiERA^ttTTlCS 


Percentage  Solution  Table. 

Showing  the  quantity  of  drug  and  water  to  use  for  prepar- 
ing aqueous  solutions  of  different  strengths.  In  these  calcula- 
tions 456  grains  have  been  taken  as  the  Aveight  of  one  fluidounce 
of  distilled  Avater  at  ordinary  temperature. 


Water 


Grains  of  Drug:  to  Make  a  Solution  Containing 


Fluid  1  in     1  in     1  in 

ounces    5000  i  2000     1000 


1  in 
500 


^^% 


1% 


2%    I   3% 


4%    i   5%      10%  '20%      25%  ;  50% 


0.046 1 0.114  0.228! 
0.091 '0.228  0.456' 
0.182  0.456  0.912 
0.273  0.684   1.37 
0.365  0.912   1.82 
0.546   1.37     2.74 
0.729,1.82     3.65 
1.094  j  2.74     5.47 
11.46     3.65     7.3     I 


0.456 

0.912 

1.82 

2.73 

3.64 

5.47 

7.30 

10.94 

14.6 


1.14  2.3 
2.28'  4.6 
4.56  9.2 
6.84  13.7 
9.12  18.2 
13.68  27.4 
18.24  36.5 

27.4  55. 

36.5  |73 


4.6 
9.1 ! 
18.2 
27.4 
36.5 
54.7 
73. 


6.8 
13.7 
27.3 
41. 
54.7 
82. 
119.4 


109.5  164.4 
146.0  218.9 


11.4  22.8 
22.8'  45.6 
45.6  91.2 
68.4  136.8 
91.2  182.4 
109.5  136.8  273.6 
146.  182.4  364.8 
218.9  273.6  547.2 
291.8  364.8  729.6 


9.11 

18.2 
36.5 
54.7 
73. 


45.61 
91.2' 
182.4 
273.6 
364.8 
547. 
729. 
1094. 
1459. 


57. 

114. 
228. 
342. 
456. 
684. 
912. 


114. 

228. 

456. 

684. 

912. 
1368. 
1824. 


1368.  2736. 
1824.  3648. 


The  above  directions  yield  slightly  more  than  the  usually  prescribed  quanti- 
ties— 1  fluidounce,  2  fluidounces,  etc. — owing  to  the  increase  in  volume  caused 
by  the  drug  entering  into  solution.  In  the  case  of  the  weaker  solution — up  to 
1  or  2  per  cent. — this  increase  is  not  appreciable. 

Short  Rule  for  Determining  Percentages  in  Mixtures. 

Multiply  456  by  the  percentage  desired  and  point  off  two  right-hand  figures. 
The  figures  at  the  left  of  separatrix  will  give  the  number  of  grains  or  drops, 
456  being  the  number  of  grains  to  the  ounce.  Example:  456x4=1824; 
18.24=1814  ;   18iy4   grains  to  an  ounce  of  liquid,  a  4  per  cent  solution. 

Table  of  Solubility. 


Name 


Water 


Alcohol 


Ether  Glycerin 


Acetanilid 

Acid  arsenic 

Acid  benzoic 

Acid  boric 

Acid  carbolic 

Acid  citric 

Acid  salicylic 

Acid  tannic 

Acid  tartaric 

Acid  trichloracetic . . . . 

Alum 

Ammonium  bromid. .  . 
Ammonium  carbonate 


230 
80 
400 
25 
15 
1 
500 
1 
1 
readily 
12 
1.3 
4 


3.5 


3 

15 
readily 

1 
readily 

2 

2.5 
readily 


readily 

5 

3.5 

10 

10 

readily 

readily 

50 

readily 

readily 

2 

readily 

readily 

3 

TABLE   OF   SOLUBILITY 


85 


Table  of  Solubility — Continued. 


Name 


Water 


Alcohol 


Ether 


Glycerin 


Ammonium  chlorid 

Antipyrin 

Apomorphin  hydrochlorid 

Atropin  sulphate 

Borax 

Camphor 

Caflfein 

Chloral  hydrate 

Cocain  hydrochlorid 

Copper  sulphate 

lodin 

Iodoform 

lodol 

Iron  sulphate 

Lithium  carbonate 

Magnesium  sulphate 

Menthol 

Mercuric  chlorid 

Morphin  hydrochlorid.. . . 

Morphin  sulphate 

Phenacetin 

Pilocarpin  hydrochlorid . . 

Potassium  acetate 

Potassium  bicarbonate. .  . 

Potassium  bromid 

Potassium  carbonate 

Potassium  chlorate 

Potassium  iodid 

Potassium  permanganate. 

Potassium  sulphate 

Potassium  tartrate 

Quinin  hydrochlorid 

Quinin  sulphate 

Resorcinol 

Saccharin 

Salol 

Silver  nitrate 

Sodium  acetate 

Sodium  benzoate 

Sodium  bicarbonate.    . . . . 

Sodium  bromid 

Sodium  carbonate 

Sodium  chlorid 

Sodium  phosphate 

Sodium  salicylate 

Sodium  sulphate 

Strychnin  sulphate 

Sugar 

Tartar  emetic 

Thymol 

Zinc  sulphate 


3 
1 

35 
1 

17 


80 
readily 

0.5 

4 
5000 

'  '5000 

2 

80 

1 

difficult 

16 

25 

20 

1400 

10 

0.5 

4 

2 

1 

16 

1 

21 

10 

1 

34 

800 

1 

250 

"  "  0.6 ' 

3 

2 
12 

1.2 

2 

3 

6 

1 

3 
31 

0.5 
17 
1100 

0.6 


1 
35 
10 


readily 

50 

readily 

4 


10 

50 

3 


readily 

3 

50 

'  i'e"  ■ 

readily 
2 

' '  200'  ' 


130 
12 


3 
90 

0.5 
25 
10 
10 
30 


6 
65' 


50 


readily 

300 

readily 


3 

6 

15 


readily 
4 


0.5 
0.3 


readily 

readily 
"  '4"    " 


15 
5 
5 


readily 

4 

15 

32 

2.5 

explosive 


readily 
15 
13 

4 

1 

5 
difficult 
difficult 
readily 

1 


readily 
■3      ■ 


86 


GENERAL   THERAPEUTICS 

Number  of  Drops  in  a  Fluidram. 


Table   showing  number   of  drops   in   a  fluidram   of  different 
liquids,  with  weight  in  grains  and  in  grams: 


Name 


Drops  in 

1  fluidram  (60m) 


Weight  of  1  fluidram 


In  grains 


In  grams 


Acid,  aceticum 

Acid,  aceticum  dilut. . . . 

Acid,  hydrochlor 

Acid,  hydrochlor.  dilut.. 

Acid,  lacticum 

Acid,  nitricum 

Acid,  nitricum  dilut.  .  .  . 

Acid,  sulphur 

Acid,  sulphur,  aromat.. . 

Acid,  sulphur,  dilut 

iEther  fortior 

Alcohol 

Aqua 

Aqua  ammon.  fortior. . . 
Chloroform,  purificat. .  . 

Creosotum 

Glycerinum 

Hydrargyrum 

Liq,  potassi  arsenitis.. . . 

Oleum  caryophylli 

Oleum  cinnamomi 

Oleum  gaultherise 

Phenol  liquid 

Spiritus  ammon.  aromat 

Syrupus 

Tinctura  aconiti 

Tinctura  iodi 

Tinctura  opii 


108 

68 

70 

60 

111 

102 

60 

128 

146 

60 

176 

146 

60 

66 

250 

122 

67 

150 

57 

130 

126 

125 

111 

142 

65 

146 

148 

130 


58 

3.75 

55 

3.56 

65 

3.62 

56 

3.49 

66 

4.27 

77 

4.98 

58 

3.62 

101 

6.54 

53 

3.43 

58  H 

3.79 

39 

2.52 

44 

2.85 

55 

3.56 

50 

3.24 

80 

5.18 

56  K 

3.66 

68 

4.40 

760 

49.24 

55 

3.56 

57 

3.69 

53^ 

3.46 

62 

4.01 

59 

3.82 

48 

3.11 

72 

4.66 

46 

2.98 

47 

3.04 

53 

3.43 

THE  PHARMACOPEIA  AND  PHARMACEUTIC 
PREPARATIONS. 

The  Pharmacopeia. 

In  all  civilized  countries  the  governments  have  found  it  neces- 
sary to  issue  at  certain  intervals  a  standard  guide  for  the  regula- 
tion of  medicinal  preparations  kept  in  the  drug  stores  for  dispens- 
ing purposes.  This  book  is  termed  a  Pharmacopeia — from 
pharmakon  (a  drug)  and  poiein  (to  make).  The  United  States 
government,  however,  does  not  issue  the  Pharmacopeia,  but  it  rec- 


PHARMACOPEIA    AND   PHARMACEUTIC    PREPARATIONS  87 

ognizes  its  authority  as  published  by  the  National  Committee  of 
Revision,  a  body  composed  of  members  by  appointment  or  elected 
by  a  convention  of  the  various  medical  and  pharmaceutic  socie- 
ties, schools,  and  United  States  Medical  Corps.  The  book  is  re- 
vised every  ten  years,  the  present  edition  being  the  Ninth  Decen- 
nial Revision,  published  by  authority  of  the  United  States  Phar- 
maceutical Convention,  held  in  "Washington,  D.  C,  in  1910.  The 
Pharmacopeia  furnishes  the  official  standard  for  the  identification, 
purity,  strength,  and  quality,  with  suitable  directions  for  prepara- 
tion, purification,  and  preservation,  of  drugs,  chemicals,  and  me- 
dicinal preparations.  The  title  of  the  drug  is  given  in  Latin,  fol- 
lowed by  the  English  name,  and,  in  the  case  of  chemicals,  by  the 
formula  and  molecular  weight.  The  preparations  contained  in 
the  Pharmacopeia  are  therefore  termed  "official,"  while  all  other 
medical  substances  usually  kept  in  a  drug  store  are  termed  "non- 
official"  or  "officinal" — from  officin,  an  ancient  name  for  the 
apothecary's  shop.  Drugs  which  were  at  one  time  "official"  are 
frequently  termed  "obsolete."  Quite  a  number  of  much  used 
preparations  which  are  not  contained  in  the  United  States  Phar- 
macopeia are  standardized  by  having  their  formulas  published  in 
the  National  Formulary,  a  book  published  and  revised  at  intervals 
under  the  direction  of  the  American  Pharmaceutical  Association. 
Another  very  large  class  of  remedies  are  those  substances  which 
are  usually  termed  tJie  newer  remedies.  These  agents  are  either 
too  new  to  have  gained  recognition  by  the  Committee  on  Revision 
of  the  Pharmacopeia,  or  they  possess  so  little  real  merit  that  they 
have  been  purposely  omitted,  although  they  are  very  largely  pre- 
scribed. To  somewhat  clarify  this  chaos  of  grain  and  chaff,  the 
American  Medical  Association  in  1906  created  a  Council  of 
Pharmacy  and  Chemistry,  whose  duty  it  is  to  select  from  the 
enormous  mass  of  these  articles  those  which  have  their  definite 
constituents  or  formulas  published,  or  otherwise  comply  with  the 
rulings  of  this  body.  At  present  (1917)  there  are  about  twelve 
hundred  of  these  articles  tentatively  approved  by  the  above  named 
Council,  and  they  are  termed  new  and  non-official  remedies. 

The  pharmacopeias  of  different  countries  vary  greatly  not  only 
with  regard  to  the  drugs  they  contain  but  also  as  regards  strength 
and  composition  of  preparations  and  similar  names.  To  over- 
come these  difficulties  a  tentative  attempt  has  been  made  to  unify 
pharmacopeial   formulas   of  potent  drugs.     The   governments  of 


88  GENERAL   THERAPEUTICS 

Great  Britain,  Germany,  Aiistria-Hungarj^,  Belgium,  Bulgaria. 
Denmark,  Spain,  the  United  States  of  America,  France,  Greece. 
Italy,  the  Grand  Duchy  of  Luxembourg,  Norway,  the  Netherlands, 
Portugal,  Russia,  Servia,  Sweden,  and  Switzerland,  having  recog- 
nized the  utility  of  concluding  an  agreement  with  the  view  to  the 
unification  of  the  pharmacopeial  formulas  for  potent  drugs  on 
the  basis  indicated  in  the  Final  Protocol  signed  on  September  20, 
1902,  as  a  result  of  the  conference  held  at  Brussels,  have  agreed 
upon  the  following  stipulations:  (a)  No  potent  drug  shall  be 
directed  to  be  prepared  in  the  form  of  a  medicinal  wine,  (b) 
Tinctures  of  potent  drugs  shall  be  directed  to  be  prepared  of  the 
strength  of  10  per  cent  and  by  percolation,  (c)  Fluid  extracts 
of  potent  drugs  shall  be  prepared  of  the  strength  of  100  per  cent, 
(d)  The  Contracting  Governments  shall  adopt  a  normal  drop- 
measure,  the  external  diameter  of  whose  outlet  tube  shall  be  ex- 
actly 3  millimeters,  that  is  to  say,  which,  at  a  temperature  of  15 
degrees  centigrade  and  with  distilled  water,  shall  yield  20  drops 
to  the  gram. 

Besides  the  Pharmacopeia  and  National  Formulary  there  are 
books  which  contain  descriptive  m.atter  of  substances  used  in 
medicine,  with  various  detailed  information.  These  books  are  com- 
pilations and  commentaries  on  the  above  works,  and  are  termed 
dispensatories.  Various  books  of  this  character  are  published  in 
the  United  States — The  United  States  Dispensatory  and  the  Na- 
tional Standard  Dispensatory  being  in  general  use. 

CONSTITUENTS  OF  ORGANIC  DRUGS. 

Organic  drugs  are  composed  of  medicinally  active  constituents 
and  of  medicinally  inactive  constituents. 

The  inert  constituents  are  principally  cellulose,  wood,  starch, 
albumen,  wax,  fat,  coloring  matter,  etc.,  which  exhibit  practically 
no  pharmacologic  action  although  they  may  modify  the  activity  of 
the  pharmacologic  principle. 

The  active  constituents  may  comprise  pharmacologically  active 
principles,  i.e.,  they  act  on  the  animal  tissues,  and  pharmaceutically 
active  principles,  i.  e  .,  they  may  cause  precipitation  or  otherAvise 
chemically  influence  a  mixture  or  compound.  The  physiologic  ac- 
tion of  a  drug  depends,  either  wholly  or  in  part,  upon  its  active 
principles. 


CONSTITUKNTS    OF    OUUANIC    DRUGS  89 

The  active  constituents  of  organic  drugs  may  be  divided  into : 

Plant  or  Organic  Acids  and  Their  Salts. — Tartaric  acid  of 
grapes,  citric  acid  of  lemon,  tannic  acid  of  oak  bark,  salicylic  acid  of 
sweet  birch,  etc.,  are  representatives  of  this  class. 

Alkaloids. — They  are  natural  organic  bases  containing  prin- 
cipally carbon,  hydrogen  and  nitrogen ;  they  possess  the  power  of 
neutralizing  acids  with  the  formation  of  salts  without  the  elimi- 
nation of  hydrogen.  All  alkaloids  (caffein  excepted)  have  cer- 
tain properties  in  common;  they  have  a  bitter  taste,  turn  red  lit- 
mus paper  blue,  have  a  profound  physiologic  action  and  leave  no 
post-mortem  changes.  They  are  soluble  in  ether,  chloroform,  and 
oils,  less  so  in  alcohol,  and  are  comparatively  insoluble  in  water. 
Alkaloidal  salts  are  soluble  in  water  and  alcohol,  but  are  insoluble 
in  ether  or  chloroform. 

Examples : 


Atropin  sulphate, 
Cocain  hydrochlorid, 
Codein  phosphate, 


Morphin  sulphate, 
Strychnin  sulphate, 
Pilocarpin  hydrochlorid. 


Glucosides. — They  are  proximate  principles  existing  in  plants 
and  in  most  instances  are  chemically  neutral  bodies.  When  treated 
with  strong  acids,  they  decompose  and  form  sugar  with  one  or 
more  other  bodies.  They  do  not  follow  rules  in  regard  to  taste, 
solubility  or  importance. 

Examples : 


Digitalin, 
Glycyrrhizin, 


Salicin, 
Strophantin. 


A  number  of  other  substances  gcnerically  known  as  neutral  prin- 
ciples and  which  very  closely  resemble  glucosides,  may  also  be 
present  in  organic  drugs.  They  are  practically  insoluble  in  water 
and  have  a  more  or  less  pronounced  bitter  taste. 

Tannins. — They  are  an  ill-defined  class  of  substances,  deriva- 
tives of  benzol,  and  distinguished  by  giving  a  bluish-green  color 
with  ferric  salts.  They  are  soluble  in  water  and  alcohol  but  readily 
form  insoluble  compounds  with  many  substances,  i.e.,  metallic  salts, 
alkaloids,  proteins,  etc.  This  precipitation  leads  to  astringent  ac- 
tion.   Tannins  may  be  physiologic  or  pathologic  products  of  plants. 

Sugars,  Starches  and  Gums. — These  compounds  are  known  as 
carbohydrates;  they  possess  only  slight  importance  as  remedies. 


90  GENERAL   THERAPEUTICS 

being  usually  employed  for  their  soothing  action  as  demulcents, 
dietetics,  and  in  the  arts.  They  constitute  one  of  the  most  im- 
portant classes  of  useful  products  of  nature. 

Ferments. — They  are  substances  capable  of  producing  chemic 
changes  without  entering  into  the  reaction  or  forming  a  part  of 
the  end-product.     Examples:     Pepsin,  panereatin,  papain. 

Resins. — They  are  alcohol  soluble  constituents  of  vegetable 
drugs,  as:    Podophyllin,  jalapin. 

Oleoresins. — They  are  ether  soluble  constituents  of  vegetable 
drugs,  as:     Copaiba,  male  fern,  capsicum. 

Balsams. — They  are  mixtures  of  resins  and  oleoresins  contain- 
ing benzoic  acid,  cinnamic  acid,  etc.  The  chief  balsams  are  those 
of  pcru,  of  tolu,  and  storax. 

Camphors. — They  are  insoluble  in  water  but  soluble  in  alcohol, 
ether,  etc.,  as :  camphor,  eucalyptol,  menthol,  etc. 

Gumresins. — They  are  mixtures  of  gum  with  resins  or  oleo- 
resins and  soluble  in  diluted  alcohol,  as:  asafetida,  ammoniac, 
myrrh  and  gamboge. 

Gums. — They  are  water  soluble  substances  which  are  readily 
precipitated  by  alcohol,  as:  gum  arable,  tragacanth,  etc. 

Fixed  Oils. — They  are  usually  obtained  by  expression  and  are 
not  readily  volatilized,  as :  castor  oil,  linseed  oil,  olive  oil,  etc. 

Volatile  Oils. — They  are  usually  obtained  by  distillation,  as: 
oils  of  cassia,  cloves,  eucalyptus,  etc. 

Pharmaceutic  Methods. 

Comminution. — Reducing  drugs  to  smaller  pieces. 

Decantation. — Drawing  or  pouring  off  a  supernatant  liquid 
into  another  vessel. 

Desiccation,  or  Drying. — To  drive  off  some  volatile  constitu- 
ent from  the  solid,  the  fixed  residue  being  the  portion  desired. 
Crude  drugs  are  subjected  to  this  method  to  reduce  their  bulk, 
to  assist  preservation,  and  to  facilitate  comminution.  Drying 
may  be  accomplished  in  spreading  the  drugs  in  airy  lofts,  or  by 
heat  in  drying  closets.  Care  must  be  taken  not  to  injure  the 
volatile  ingredients  of  the  drugs. 

Distillation. — Evaporation  of  a  liquid  and  condensing  the 
vapor  into  a  liquid  in  a  separate  vessel.     Fractional  distillation 


PHARMACEUTIC    METHODS 


91 


is  the  process  of  separating  a  mixture  of  liquids  of  different  boil- 
ing points  by  distillation. 

Evaporation, — Vaporizing  a  solvent  from  a  solution  so  as  to 
concentrate  the  dissolved  substance. 

Expression. — Separation  of  liquids  from  solids  by  pressure. 

Exsiccation,  or  Calcination. — Depriving  a  solid  of  its  mois- 
ture or  volatile  constituents  by  heat  without  fusion. 


Fig.  13. 
Percolation. 

Filtration. — Separation  of  liquids  from  suspended  solids  by 
pouring  them  through  a  filter  medium — as  filter  paper,  charcoal, 
sand,  etc. 

Maceration. — Dissolving  soluble  active  constituents  of  drugs 
by  suspending  them  in  a  menstruum  for  a  sufficient  length  of 
time. 


92  GENERAL   THERAPEUTICS 

Precipitation. — Separating  solids  from  their  solvents,  which  is 
usually  accomplished  by  chemic  or  physical  means. 

Percolation,  or  Displacement. — A  process  of  exhausting  a 
drug  by  a  suitable  menstruum.  It  consists  in  "subjecting  a  sub- 
stance or  mixture  of  substances  in  powder,  contained  in  a  vessel 
called  a  percolator,  to  the  solvent  action  of  successive  portions  of 
a  certain  menstruum  in  such  a  manner  that  the  liquid,  as  it  trav- 


Fig.   14.  Fig.   15. 

Infusion   jar.  Casserol  for  decoction. 


erses  the  powder  in  its  descent  to  a  receiver,  shall  be  charged 
with  the  soluble  portion  of  it,  and  pass  through  the  percolator  free 
from  insoluble  matter."     (U.  S.  Pharmacopeia.) 

Solution. — The  diffusion  of  solid  molecules  in  a  liquid  in  such 
a  manner  as  to  become  widely  separated,  with  no  solid  particles 
discernible  by  any  means.  A  simple  solution  is  purely  a  physical 
process,  as  the  substance  undergoes  no  alteration.  A  chemic  solu- 
tion is  a  chemic  alteration  of  the  dissolved  body  by  the  solvent. 
If  a  solution  is  fully  charged  with  the '  dissolved  substances  so  as 
not  to  retain  any  more  of  it,  it  is  termed  a  saturated  solution.  A 
saturated  solution  of  one  substance  is  still  capable  of  dissolving 
other  bodies  to  a  limited  extent.  Circulatory  solutions  dissolve 
or  exhaust  a  substance  which  is  suspended  in  the  solvent.  The 
process  of  making  a  simple  solution  depresses  and  that  of  a  chemic 
solution  raises  the  temperature  of  the  solvent. 

Sublimation. — Separating  a  volatile  from  a  nonvolatile  solid. 
Trituration. — Rul)bii)g  a  substcinee  to  a  very  fine  powder  in 
a  mortar. 


PHARMACEUTIC  PREPARATIONS 


03 


Pharmaceutic  Preparations. 

Capsules    (Capsule). — Gelatin  coverings  of  various  sizes  for 
drugs. 

KoNSEALS  (rice  flour  capsules)  or  wafers  (thin  sheets  of  dried 
flour  paste)  are  sometimes  used  to  enclose  drug  powders. 


Fig.   16. 
Empty  gelatin   capsules. 


Cerates  (Cerata). — Unctuous  preparations  similar  to  oint- 
ments, having  for  their  bases  the  simple  cerate,  composed  of  30 
parts  white  wax,  20  jjarts  petrolatum,  50  parts  bcnzoinated  lard — 
as  camphor  cerate. 


"^ 


Fig.  17. 
Konseals.     (Rice  flour  capsules.) 


Collodions  (Collodia). — Liquid  preparations  having  for  their 
base  a  solution  of  gun  cotton  (pyroxylin)  in  a  mixture  of  ether 
and  alcohol — as  flexible  collodion. 


94  GENERAL    THERAPEUTICS 

Confections  (Confectiones). — Medicinal  substances  formed  in- 
to a  mass  with  sugar,  honey,  and  water — as  confection  of  rose. 

Decoctions  (Decoctiones). — Vegetable  substances  boiled  in 
water  and  strained — as  decoction  of  sarsaparilla. 

Elixirs  (Elixiria). — Sweetened,  spirituous  preparations  contain- 
ing medicinal  substances  in  small  quantities — as  elixir  of  gentian. 

Emulsions  (Emulsia). — Aqueous  preparations  in  which  oils, 
oleoresins,  balsams,  resins,  or  other  substances  which  are  insoluble 
in  water  are  suspended  by  means  of  gum  or  other  viscid  excipients 
— as  cod-liver  oil  emulsion. 

Extracts  (Extracta). — Solid  or  semi-solid  substances  of  ac- 
tive principles  of  drugs — as  extract  of  opium. 

Fluid  Extracts  (Fluidextracta). — Active  principles  of  drugs 
prepared  by  percolation.  They  are  liquid,  and  one  gram  of  the 
drug  corresponds  to  one  cubic  centimeter  of  the  finished  product 
— as  fluid  extract  of  ergot. 

Gargles  (Gargarisma). — Mixtures  or  solutions  for  application 
to  the  pharynx  or  to  the  mouth. 

Glycerites  (Glycerita). — Mixtures  or  solutions  of  medicinal 
substances  with  or  in  glycerin — as  glycerite  of  tannic  acid. 

Honeys   (Mellita). — ^Vehicles  for  drugs — as  honey  of  rose. 

Infusions  (Infusa). — Comminuted  drugs  exhausted  with  hot 
or  cold  water — as  infusion  of  digitalis. 

Injections  (Injectiones). — Liquid  preparations  for  introduc- 
tion into  the  cavities  of  the  body  by  means  of  a  syringe. 

Juices  (Succi). — Expressed  juices  of  fresh  drugs — as  lemon 
juice. 

Liniments  (Linimenta). — Liquid  ointments  to  be  applied  with 
friction  to  the  skin — as  soap  liniment. 

Lotions  (Lotiones). — Mixtures  or  solutions  of  medicinal  agents 
for  external  application. 

Masses  (Mass^e). — Dough  mixtures  of  pillular  consistency  for 
making  pills — as  mass  of  mercury. 

Mixtures  (Mistur^). — Solids  suspended  in  aqueous  liquids — 
as  chalk  mixture. 

Mucilages  (Mucilagines). — Gums  dissolved  in  water — as  mu- 
cilage of  acacia. 

Ointments  (Unguenta). — Soft,  fatty  mixtures  melting  by  fric- 
tion at  body  temperature — as  zinc  ointment. 

Oleates  (Oleata). — Solutions  of  metallic  salts  or  alkaloids  in 
oleic  acid — as  oleate  of  mercury. 


PHARMACEUTIC   PREPARATIONS 


95 


Oleoresins  (Oleoresin^). — Natural — as  copaiva  and  turpen- 
tine; or  artificially  prepared  by  extracting  drugs  with  ether — as 
oleoresin  of  ginger. 

Papers  (Chart^e). — Paper  impregnated  with  medicinal  sub- 
stances—as mustard  paper. 

Pills  (Pilule). — Small  spherical  bodies,  containing  medicinal 
substances  by  aid  of  some  vehicle  and  covered  with  various  sub- 


stances— as  cathartic  pills.  (Dragee,  granule,  and  bolus  are  modi- 
fications of  pills.) 

Plasters  (Emplastra). — Adhesive,  fatty,  or  resinous  com- 
pounds spread  on  textile  fibers,  leather,  muslin,  etc.,  and  are  either 
dry  or  soft — as  lead  plaster. 

Poultices  (Cataplasmata). — Means  of  applying  heat  and 
moisture  to  certain  parts  of  the  body — as  cataplasm  of  kaolin. 


Fig.   19. 
Suppository   mould. 

Powders  (Pulveres). — Drug  mixtures  in  very  fine  state  of 
division — as  Dover's  powder. 

Resins  (Resins). — Natural  exudations — as  rosin;  or  artificially 
prepared  principles  of  drugs — as  resin  of  jalap. 

Solutions  (Liquores). — Watery  solutions  of  non-volatile  sub- 
stances— as  solutions  of  magnesium  citrate. 

Spirits  (Spiritus). — Solution  of  volatile  substances  in  alcohol 
— as  spirit  of  peppermint. 


96 


GENERAL   THERAPEUTICS 


Suppositories  (Suppositoria).^ — Medicines  mixed  with  cocoa  but- 
ter and  formed  into  cones  intended  for  introduction  into  the 
rectum  or  vagina;  for  urethral  use  they  are  called  bougies — as 
glycerin  suppositories. 

Syrups  (Syrupi).- — Solutions  of  various  kinds  containing  largo 
quantities  of  sugar — as  syrup  of  tolu. 

Tinctures  (Tincture). ^ — Solutions  of  medicinal  active  con- 
stituents of  drugs  in  an  alcoholic  menstruum — as  tincture  of  kra- 
meria. 


Fig.   20. 
Finished  suppository. 


Triturations  (Triturationes). — Intimate  mixtures  of  one  part 
of  the  substance  with  nine  parts  of  sugar  of  milk. 

Troches  (Trochisci). — Small  compressed  tablets  or  cakes  of 
some  medicinal  substances  with  some  vehicle — as  troches  of  san- 
tonin. 

Vinegars  (Aceta).- — Solutions  of  active  principles  of  drugs  in 
dilute  acetic  acid — as  vinegar  of  squills. 

Waters  (Aqu.e). — Solutions  of  volatile  substances  in  water — 
ns  rose  water. 


SYNOPSIS    OF    NATIONAL    NARCOTIC    LAW 


97 


Wines  (Vina). — Solutions  of  medicinal  substances  in  wine — as 
wine  of  opium. 


"»  ••  «»  » '4»s  mni^^  mt 


Fig.   22. 
Hypodermic  tablet  mould. 


SYNOPSIS    OF   THE   NATIONAL   NARCOTIC    (HARRISON) 
LAW  AS  IT  AFFECTS  THE  DENTAL  PRACTITIONER. 

On  March  1,  1915,  the  National  Narcotic  (Harrison  Antinar- 
cotic  Bill,  H,  E.  6282)  Law,  went  into  effect.  This  law*  has  in 
many  respects  a  direct  bearing  on  the  practice  of  dentistry,  as 
the  two  basic  drugs  to  which  it  refers — namely,  opium  and  cocain 
and  their  derivatives — are  quite  frequently  employed  by  the  den- 
tal practitioner.  The  following  summary  is  a  synopsis  of  the  law 
as  it  affects  the  dentist : 

(1)  The  law  provides  that  on  and  after  July,  1915,  and  annually  there- 
after, every  person,  firm,  or  corporation  that  imports,  manufactures,  com- 
pounds, deals  in,  disposes  of,  sells,  distributes,  or  gives  away  opium,  or 
coca  leaves,  or  any  compound,  manufacture,  salt,  derivative,  or  prepara- 
tion thereof,  shall  register  with  the  Collector  of  Internal  Eevenue  of  the 
district  in  which  he  resides,  his  name  or  style  and  his  place  of  business. 
Persons  registered  under  this  law  will  be  held  responsible  for  the  acts  of 
their  employees  in  dispensing  or  distributing  any  of  the  drugs  coming 
within  the  scope  of  this  law.  Where  two  or  more  dentists  are  in  partner- 
ship, doing  business  under  a  firm  name,  it  is  necessary  for  the  firm  to  be 
registered,  the  firm  registry  number  to  be  indicated  in  ordering  any  of 
the  drugs  for  use  in  the  office  practice  of  the  members  of  the  firm,  each 
individual  dentist  in  such  partnership  should  register  and  pay  the  an- 
nual tax  under  his   own  name,   if  also   engaged  in   private   practice.     If 


•In  a  recent  (April,  1917)  decision  rendered  by  the  United  States  Circuit  Court  of  Ap- 
peals for  the  Second  Circuit  confirming  the  decision  of  the  United  States  District  Court- 
it  was  held  that  novocain,  anesthesin,  orthoform  and  holocain  do  not  come  under  the 
National  Narcotic  (Harrison)  Law  and,  therefore,  dentists  prescribing  or  using  these 
drugs  may  do  so  under  the  above  ruling  without  registering  or  employing  the  Harrison 
narcotic  blanks  in  ordering  them. 


98 


GENERAL   THERAPEUTICS 


maintaining    an    office    in    more    than    one    internal    revenue    district    must 
register  in  each  district. 

(2)  The  specified  drugs  may  be  purchased  only  uj^on  official  order 
blanks  issued  by  the  Internal  Revenue  Department,  at  a  cost  of  one  cent 
each  for  each  original  order  or  duplicate  thereof.  Whenever  the  dentist 
orders  any  of  the  above-named  drugs  he  must  fill  out  the  official  order 
blank,  retaining  the  duplicate  copy  thereof  for  two  years  and  in  a  man 
ner  open  to  inspection  by  the  proper  authorities. 

(3)  The  dispensing  or  distribution  of  any  of  the  aforesaid  drugs  to 
a  patient  by  a  dentist  duly  registered  under  the  act,  in  the  course  of  his 
professional  practice  only,  is  not  interfered  with  by  this  law,  nor  does 
the  law  apply  to  the  sale  or  disposal  in  any  way  of  the  said  drugs  by  a 
dealer  on  the  written  prescription  of  a  dentist.  But  such  prescriptions 
must  be  dated  as  of  the  date  on  which  they  were  signed  and  must  bear 
the  signature  of  the  dentist  who  issued  the  same.  A  duplicate  copy 
thereof  should  be  retained  for  two  years  by  the  prescriber. 


Record  of  Narcotics  Dispensed  or  Distributed 


KINO  OF  ORUb 


PATIENT'S  NAMfc 


PATIENT'S  ADDRESS 


Fig.  23. 
Sample  page  of  record  of  narcotic  drugs  dispensed. 


(4)  The  dentist  may  dispense  without  restriction  to  his  patients  the 
prescribed  drugs  when  he  personally  attends  upon  his  patient,  in  the  course 
of  his  professional  practice.  If  the  dentist  does  not  personally  attend  upon 
the  patient  and  distributes  or  dispenses  any  of  the  prescribed  drugs  he 
must  keep  a  record  of  such  drugs  so  dispensed  or  distributed,  the  amount 
dispensed  or  distributed  in  each  instance,  the  date,  and  the  name  and 
address  of  the  patient.  It  will  be  noted  that  this  record  is  only  required 
when  the  dentist  does  not  personally  attend  upon  the  patient. 

(5)  The  law  exempts  from  its  provisions  all  preparations  and  remedies 
which  do  not  contain  more  than  two  grains  of  opium,  or  more  than  one- 
fourth  grain  of  morphin,  or  more  than  one-eighth  grain  of  heroin,  or 
more  than  one  grain  of  codein,  or  of  any  salt  or  derivative  of  any  of 
them,  in  one  fluidounce,  or,  if  a  solid  or  semisolid  preparation,  in  one 
avoirdupois  ounce;  all  liniments,  ointments,  and  preparations  which  are 
prepared  for  external  use  only,  except  liniments,  ointments,  and  other 
preparations  which  contain  cocain  or  any  of  its  salts,  or  any  synthetic 
substitute  for  them.  The  exemptions  as  to  the  preparations  above  named 
apply  only  when  they  are  sold,  distributed,  given  away,  dispensed,  or 
otherwise   disposed   of  as  medicines  and   not   for  the   purpose  .of  evading 


SYNOPSIS    OF    NATIONAL    NARCOTIC    LAW  99 

tlic  provisiuiis  of  the  act.  Dentists  using  in  ofSce  practice  cocain  and 
similar  drugs  are  permitted  to  make  up  stock  solutions,  recording  only,  the 
date  of  jjreparatiou  and  the  date  of  exhaustion  of  same. 

(G)  It  is  a  crime  under  the  act  for  any  i:)erson  who  is  not  registered 
and  has  not  i)aid  the  tax  to  have  in  his  possession  or  under  his  control 
any  of  the  aforesaid  drugs,  and  such  possession  will  be  construed  as  pre- 
sumptive evidence  of  a  violation  of  the  act.  This  provision,  however,  docs 
not  apply  to  any  employee  of  a  registered  person,  or  to  a  nurse  under  the 
supervision  of  a  dentist  registered  under  the  act,  having  such  possession 
by  virtue  of  his  employment  or  occupation  and  not  on  his  own  account. 
This  act  in  no  way  interferes  with  the  operation  of  the  laws  of  any  State 
respecting  the  manufacture,  sale,  or  use  of  narcotic  drugs  unless  such 
laws  are  in  direct  conflict  therewith. 

The  penalty  for  violating  any  of  the  requirements  of  the  act  is  a  fine 
of  $2,000,  or  imprisonment  for  not  more  than  five  years,  or  both,  in  the 
discretion  of  the  court. 

From  all  appearances,  all  local  anesthetic  solutions,  tablets,  pel- 
lets, pastes,  etc.,  containing  cocain  or  opium,  or  any  of  their  de- 
rivatives, are  amenable  to  this  law.  Liniments,  ointments,  or  other 
preparations  containing  drugs  not  specifically  exempt,  used  for 
oral,  nasal,  aural,  ocular,  rectal,  urethral,  or  vaginal  administra- 
tion are  not  in  such  cases  used  externally  and  are  therefore  not 
exempt  from  the  provisions  of  this  law. 

Tropacocain  is  a  synthetic  product  of  cocain,  consequently  its 
sale  will  be  governed  by  the  law,  while  chloretone,  i.e.,  aceton- 
chloroform,  and  quinin  and  urea  hydrochlorid  are  not  affected 
by  it. 

The  practitioner  who  purchases  ready-made  solutions,  tablets 
or  other  pharmaceutic  compounds  should  carefully  ?'ead  the  at- 
tached labels  so  as  to  familiarize  himself  with  the  components 
of  the  respective  preparations.  Aside  from  the  before-mentioned 
drugs  there  are  a  number  of  pharmaceutic  preparations  employed 
by  the  dental  practitioner  upon  which  the  new  law  has  a  direct 
bearing.  The  most  important  compounds  are  herewith  enumer- 
ated: Fluid  extracts,  tinctures,  and  elixirs,  powders,  pills,  tab- 
lets (compressed  and  hypodermic),  and  pastes  containing  opium, 
coca,  or  their  derivatives,  such  preparations  including  the  follow- 
ing compounds:  Warburg's  tincture,  Dover's  powder,  ipecac  and 
opium  pills,  BroAvn's  chlorodyne,  brown  troches,  TuUy's  powder, 
opium  and  lead  wash,  some  of  the  anti-neuralgic  liniments,  most 
of  the  pulp-devitalizing  compounds,  and  such  local  styptics  as 
stypticin  (cotarnin  hydrochlorid)  or  styptol  (cotarnin  phthalate), 


100 


GENERAL   THERAPEUTICS 


and  the  occasionally  internally  employed  hemostatic — camphor, 
opium,  and  lead  acetate  pill.  Many  of  the  anodyne  compounds 
which  are  administered  by  the  dentist  as  pain-relievers  contain 
opium  or  its  derivatives,  i.e.,  eodein,  heroin,  morphin,  etc.  Inci- 
dentally, this  is  equally  true  of  most  cholera  drops  and  cough 
mixtures.  Preparations  for  the  mouth  and  teeth  in  the  form  of 
washes,  powders,  pastes,  and  soaps  are  usually  free  from  opium 
or  cocain  admixtures,  while  a  number  of  other  pharmaceutic  com- 
pounds used  by  the  dentist  contain  these  drugs.  Merely  to  enu- 
merate a  few,  the  following  preparations  may  serve  as  examples: 
A  widely  advertised  abscess  cure  contains  morphin;  mummifying 
pastes  are  known  to  contain  cocain.  This  is  equally  true  of  cer- 
tain antiseptic  and  anesthetic  pastes  employed  for  polishing  teeth 
and  massaging  the  gums.  It  may  seem  ridiculous,  but  neverthe- 
less it  is  true  that  even  some  root-filling  compounds  are  known  to 
contain  morphin. 

AVERAGE  DOSES  OF  THE  MOST  IMPORTANT 
DENTAL  DRUGS. 


Drugs. 


Acetanilid    

Acetphenetitin    (see  Phenacetin) 

Acid,  acetic,  diluted  (Vinegar;  6%) 

benzoic    

boric     

carbolic  (see  Phenol,  liquefied) 

hydrochloric,  diluted   (10%) 

hydrocyanic,  diluted   (2%) 

nitric,   diluted   (10%) 

phosphoric,    diluted    (10%) 

salicylic 

sulphuric,   aromatic    (20%) 

sulphuric,  diluted  (10%) 

tannic    

A  conite  

' '        tincture  of,  (10%) 

Aconitin    

Aloes,    purified 

Alum    

Ammonia,  aromatic  spirit  of 

Amyl  Nitrite    

Antipyrin 

Apomorphin  hydrochlorid    (emetic) 

Arsenic  trioxid 

Sol.  pot.  arsenite  (Fowler's  solution;  1%). 
Atropin  sulphate  (see  Belladonna  leaves) . , . . , 


Grains  or 

Grams  or 

minims. 

C.c. 

3 

0.2 

30 

2. 

71/2 

0.5 

7V2 

0.5 

15 

1. 

IV2 

0.1 

30 

2. 

30 

2. 

12 

0.75 

15 

1. 

15 

1. 

7% 

0.3 

1 

0.065 

5 

0.3 

1/400 

0.00015 

4 

0.25 

7y2 

0.5 

30 

2. 

3 

0.2 

5 

0.3 

1/10 

0.005 

3 

0.002 

1/30 

0.2 

— 

— 

AVERAGE   DOSES 


101 


Average  Doses  of  the  Most  Important  Dental 
Drugs — Continued. 


Drugs. 


Belladonna   leaves 

"  tincture  of,   (10%) 

Atropin   sulphate    

Benzosulphinid   (Saccharin)    

Bismuth  subnitrate 

Blue  mass  (see  Mercury,  mass  of) . . , 

Caflfein    

' '       citrated  

Calomel  (see  Mercury,  mild  chlorid) . 

Camphor 

Cascara  sagrada  

Cerium   oxalate    

Chloral,  hydrated 

Cinchona 

Quinin  or  its  salts 

Coca 


Grains  or 
minims. 


Cocain  or  its  salts 

Codein   (see  Opium) 

Cream  of  tartar  (see  Potassium  bitartrate) 

Creosote    

Copper    sulphate    (emetic) 

Digitalis   

"  tincture   of,    (10%) 

Dover's    Powder     (see    Ipecac,    powder    of,    and 

opium)     

Emetin    (see   Ipecac) 

Epsom  Salt   (see  Magnesium  sulphate) 

Ergot     

Eucalyptol 

Eugenol    

Fowler's  solution   (see  Sol.  pot.  arsenite) 

Glauber 's  salt  (see  Sodium  sulphate) 

Glycerin    

Guaiacol   

Hexamethylenamin    (Urotropin)    

Ipecac   (expectorant  and  antiamebic) 

"        Powder   of,   and   opium    (Dover's   powder; 

of    each    10%) 

Emetin  or  its  salts 

Todid,  ferrous,  syrup  of  (5%) 

lodin,  tincture  of  (7%) 

Krameria,  tincture   of   (20%) 

Laudanum   (see  Opium,  tincture  of) 

Lead  acetate  (Sugar  of  lead) 

Lime,    syrup    of 

Lithium   and   its   salts 

Magnesium   sulphate   (Epsom   salt) 

Mercury  chlorid,  corrosive  (Corrosive  sublimate). 

' '  chlorid,  mild   (Calomel) 

"  iodid,   yellow    (Protiodid) 

"         mass  of,   (Blue  mass;  33%) 

Morphin    (sec   Opium) 


1 

12 

1/120 
2 

8 

2 1/2 
5 

1/2 
15 

3 

8 
15 

4 
30 


30 
5 
3 


60 
8 
4 
1 

1/3 
15 

iy2 

fiO. 

1 

30 

8 
240 
1/20 

2V2 

1/6 
4 


Grams  or 
C.c. 

0.065 

0.75 

0.0005 

0.2 

0.5 

0.15 
0.3 

0.1 

1. 

0.2 

0.5 

1. 

0.25 

2. 

0.015 


0.25 
0.25 

0.065 
0.5 


2. 

0.3 

0.2 


4. 
0.5 
0.25 
0.06.') 

0.5 

0.022 

1. 

0.1 

4. 

0.065 
2. 
0.5 
16. 
0.003 
0.15 
0.01 
0.25 


102 


GENERAL   THERAPEUTICS 


Average  Doses  of  the  Most  Important  Dental 
Drugs — Continued. 


Drugs. 


Nitroglycerin,  spirit  of   (1%) 

Novocain   hydrochlorid    

Nux   vomica    

"  "  tincture  of,   (0.1%  strychnin) 

Strychnin   or  its  salts 

Opium   

"        granulated    (10%  morphin) 

"        tincture  of,   (Laudanum;   10%) 

"        tincture     of,    camphorated     (0.4%     opium 

Paregoric)    

' '       tincture  of,  deodorized  (10%) 

Codcin  or  its  salts 

Morphin   or   its  salts 

Oil,  Castor   

' '     Clove 

' '     Cassia    (Cinnamon)     

' '    Eucalyptus    

' '    Peppermint    

' '     Wintergreen    

Paregoric  (see  Opium,  tincture  of,  camphorated) 

Phenacetin   (Acetphcnetitin)    

Phenol,  liquefied  (Carbolic  acid,  86.4%) 

"        salicylate   (Salol)    

Phosphorus    

Pilocarpin  hydrochlorid  (hypodermic) 

Potassium  bicarbonate , 

' '  bitartrate    (Cream   of   tartar) 

' '  bromid 

' '  chlorate  

"  citrate    

"  and  sodium  tartrate   (Rochelle  salt).. 

"  iodid     

' '  sulphate    

Quinin    (see    Cinchona) — 

Rochelle  salt  (sec  Potassium  and  sodium  tartrate) .  — 

Rhubarb   15 

Saccharin    (see   Benzosulphinid) — 

Salol  (see  Phenol  salicylate) — 

Scopolamin  hydrochlorid  (hypodermic) 1  /200 

Silver  nitrate   1/5 

Sodium  bicarbonate 15 

"       bromid     15 

"        chlorid  240 

' '        phosphate (50 

"        salicylate     1.5 

' '       sulphate    (Glauber 's  salt) 240 

Strychnin  (see  Nux  Vomica) — 

Sugar  of  lead    (see  Lead  acetate) — ■ 

Sulphonmethan   (Sulphonal)    12 

Sulphur,  washed    GO 

Thymol 2 

TIrotropin   (see  Hexamethylenamin)   — 

Zinc   sulphate    (emetic) 15 


Grains  or 

Grams  or 

minims. 

C.c. 

1 

0.065 

1/2 

0.03 

1 

0.065 

8 

0.5 

1/40 

0.0015 

1 

0.06 

1 

0.06 

8 

0.5 

GO 

4. 

8 

0.5 

1/2 

0.03 

1/8 

0.008 

240 

16. 

3 

0.2 

3 

0.2 

8 

0.5 

3 

0.2 

15 

1. 

— 

— 

0 

0.3 

1 

0.06 

5 

0.3 

1/128 

0.0005 

1/12 

0.005 

15 

1. 

30 

2. 

15 

1. 

4 

0.25 

15 

1. 

150 

10. 

5 

0.3 

30 

2. 

o.ooo: 

0.01 

1. 
1. 

16. 

4. 

1. 
16. 


0.75 

4. 

0.125 


1. 


PART  II 
PHARMACO-THERAPEUTICS 


ANTISEPTICS. 


At  present  it  is  generally  recognized  that  the  breaking  down 
of  highly  organized  bodies,  when  subjected  to  certain  causative 
conditions,  is  brought  about  by  the  activity  of  minute  vegetable 
organisms — the  bacteria.  This  process  is  called  putrefaction,  or, 
under  certain  conditions,  fermentation.  These  terms  are  applied 
to  strictly  analogous  processes,  with  this  differentiation — putre- 
faction refers  to  the  decomposition  of  animal  proteins,  while  fer- 
mentation is  restricted  to  the  cleavage  action  of  bacteria  and  of 
certain  ill-defined  bodies  known  as  ferments  on  vegetable  material. 
The  presence  of  certain  bacteria  is  instrumental  in  the  produc- 
tion of  severe  physiologic  changes,  resulting  in  the  various  vital 
phenomena  known  as  infectious  diseases.  As  soon  as  this  fact 
became  recognized,  investigators  directed  their  attention  to  the 
discovery  of  agents  capable  of  inhibiting  or  destroying  the  action 
of  these  germs,  with  the  object  of  rendering  infected  or  septic 
conditions  perfectly  clean,  or  antiseptic. 

By  the  term  sepsis,  then,  we  understand  the  existence  of  a  con- 
dition in  which  bacterial  infection  and  its  sequela — fermentation 
or  putrefaction — is  brought  about  by  the  presence  of  germs  or 
their  products,  while  asepsis  implies  an  entire  freedom  from  such 
infection — that  is,  an  aseptic  condition.  If  a  primarily  septic  con- 
dition is  changed  by  some  method  or  means  that  inhibits  the 
growth  of  putrefactive  organisms,  antisepsis  is  secured.  Conse- 
quently antiseptics  are  chemic  agents  that  merely  inhibit  the  ac- 
tion and  growth  of  bacteria,  while  germicides  destroy  the  vitality 
of  the  infective  organisms.  Disinfectants  also  kill  the  bacteria, 
and  chemically  change  their  poisonous  products  to  some  inert 
compounds.  Disinfectants  must,  therefore,  be  germicides.  Thus 
it  will  be  seen  that  an  antiseptic  is  not  necessarily  a  germicide 

lO.T 


104  PHARMACO-THERAPEUTICS 

or  a  disinfectant — that  is,  glycerin  will  inhibit  the  growth  of  cer- 
tain bacteria,  and  is  therefore  antiseptic,  but  it  has  very  little  or 
no  power  to  destroy  the  micro-organisms  themselves  or  their 
spores,  and  consequently  possesses  no  germicidal  or  disinfectant 
properties.  On  the  other  hand,  formaldehyd  solution  is  an  ef- 
fective germicide,  possesses  also  powerful  disinfectant  properties, 
and  is  successfully  employed  for  both  purposes,  while  milk  of 
hypochlorid  of  lime  is  extensively  used  as  a  disinfectant,  which, 
of  course,  incidentally  means  germicidal  action. 

Quite  frequently  putrefactive  processes  are  accompanied  by  the 
production  of  malodorous  gases  arising  from  the  formation  of 
new  compounds.  Again,  agents  are  employed  to  destroy  these 
offensive  odors,  and  such  agents  are  termed  deodorants.  The  true 
deodorants  usually  have  very  little  or  no  antiseptic  action — as 
iron  sulphate.  If  an  agent  is  employed  solely  for  its  cleansing 
power,  either  mechanically  or  chemically — as  soapsuds — it  is 
termed  a  detergent,  while  all  those  chemicals  that  possess  the 
power  to  inhibit  the  action  of  ferments  are  called  antizymotics. 

The  action  of  antiseptics  depends  on  their  chemic  relationship 
to  the  albumin  of  the  cell;  they  act  as  poisons,  and  are  therefore 
closely  related  to  caustics  and  astringents.  The  ideal  antiseptic 
would  be  one  that  inhibits  or  destroys  the  bacteria  and  their 
products  without  seriously  injuring  the  cell  of  the  host.  Accord- 
ing to  our  present  conception  of  biologic  laws,  the  search  for  such 
a  material  is  apparently  fruitless. 

Antiseptics  are  usually  divided  into  those  used  for  external  or 
local  application  and  those  employed  internally.  External  anti- 
septics include  all  those  agents  that  are  used  on  the  skin,  the 
external  mucous  surfaces,  including  the  oral  cavity,  wounds,  and 
ulcers,  the  intestinal  tract,  the  bronchi  and  lungs,  and,  in  a  round- 
about way,  the  urinary  tract,  while  the  destruction  of  infectious 
material  on  instruments,  clothing,  rooms,  food,  etc.,  is  accom- 
plished by  disinfectants.  The  destruction  of  all  forms  of  bacteria 
and  their  products,  and  their  removal  from  external  surfaces,  is 
referred  to  as  sterilization,  and  is  usually  performed  by  means  of 
heat. 

The  administration  of  internal  antiseptics  is  based  on  the  sup- 
position that  the  blood  and  the  body  juices  become  saturated  with 
them  to  such  an  extent  as  to  kill  or  neutralize  the  bacteria  and 
their  waste  products  without  harming  the  tissues  themselves.     As 


ANTISEPTICS  105 

yet  very  little  is  known  about  the  action  of  antiseptics  when  ad- 
ministered in  the  above  manner.  Clinical  observations  show,  how- 
ever, that  certain  infectious  diseases — as  malaria,  syphilis,  acute 
articular  rheumatism,  probably  sepsis,  and  a  few  others — are  posi- 
tively influenced  by  such  treatment,  and  that  their  uses  are  there- 
fore justified.  Recently  efforts  have  been  made  to  introduce  anti- 
septic medication  by  inunction  or  by  intravenous  injection — as 
quinin  in  malaria,  mercury  salts  in  syphilis,  silver  compounds  and 
formaldehyd  solution  in  sepsis,  etc.  While  such  procedures,  per 
se,  may  be  justified,  they  should  not  be  followed  indiscriminately. 

When  we  speak  about  the  potency  of  any  given  antiseptic,  it 
should  be  remembered  that  this  potency  is  only  relatively  ex- 
pressed. We  have  as  yet  no  accepted  standards  of  antiseptic 
strength.  Various  efforts  have  been  made  in  this  respect;  for  in- 
stance, Rideal  and  Walker  have  attempted  to  introduce  the  so- 
called  ''phenol-coefficient."  With  the  methods  formerly  used  in 
determining  the  value  of  a  disinfectant  in  terms  of  its  phenol  co- 
efficient, the  results  that  may  be  obtained  even  by  the  same  worker 
are  misleading  and  subject  to  wide  variations.  The  Rideal-Walker 
method  is  now  extensively  used,  but  it  is  not  without  its  faults. 
The  Lancet  method,  while  not  as  simple  or  as  easily  performed 
as  the  Rideal-Walker  method,  seems  to  be  the  best  one  so  far 
proposed. 

Briefly  stated,  the  phenol  coefficient  in  the  Kideal-Walker  method  is 
arrived  at  by  dividing  the  figure  indicating  the  degree  of  dilution  of  the 
disinfectant  that  kills  an  organism  in  a  given  time  by  that  expressing  the 
degree  of  dilution  of  the  phenol  that  kills  the  same  organism  in  the  same 
time  under  exactly  similar  conditions.  Leaving  out  details,  the  determina- 
tion of  the  Eideal-Walkcr  coefficient  is  substantially  as  follows  :i 

Certain  standard  conditions  are  considered  essential  to  the  proper  per- 
formance of  the  test.  Phenol  solutions  of  known  strength  arc  used;  cul- 
tures are  grown  in  a  standard  medium,  transplants  being  made  every  24 
hours;  the  loops  used  for  all  inoculations  are  of  a  standard  size  (about  4 
mm.  in  diameter).  Usually  four  dilutions  of  suitable  strengths  of  the  dis- 
infectant to  be  used  are  made.  Phenol  controls  of  a  suitable  strength  are 
also  prepared.  Five  C.c.  of  each  of  these  dilutions  are  placed  in  sterile 
test  tubes,  to  which  are  added  at  intervals  of  one-half  minute  a  24-hour 
broth  culture  of  B.  typhosus  in  the  proportion  of  1  drop  of  culture  to  each 
cubic  centimeter  of  disinfectant  used  (according  to  Partridge,  1  drop  of 
culture  equals  about  0.1  C.c).  At  the  end  of  two  and  a  half  minutes  a 
loopful   of  each  of  the  mixtures  is  inoculated  into  a  test   tube  containing 

•Andersen  and  McClintic:  Hygienic  Laboratory  Rulletin  No.  82,  Washington,  1912. 


106 


PH  A  R  M  ACO-T  H  EK  APEUTI CS 


5  Co.  of  standard  broth,  an  interval  of  half  a  minute  being  thus  allowed 
between  taking  the  samples  from  the  different  dilutions.  This  is  repeated 
at  5,  7%,  10,  12%,  and  15  minutes.  The  broth  tubes,  after  being  in- 
cubated at  37°  C.  for  48  hours,  are  examined  for  growth.  The  results  of 
the  examination  are  then  noted,  and  if  suitable  comparative  strengths  of 
the  disinfectant  and  phenol  have  been  selected  the  phenol  coefficient  is 
determined  as  above  stated. 

The  following  table  illustrates  the  manner  of  determining  the  phenol 
coefficient  of  a  disinfectant  according  to   the   Rideal-Walker  method: 

Name,   "A." 

Temperature  of  medication,  20°   C. 

Culture  used,  B.  typhosus,  24-hour,  extract  broth,  filtered. 

Proportion  of  culture  and  disinfectant,  0.1  C.c. — 5  C.c. 


Sample 

Dilution 

Time  culture  exposed   to 
action  of  disinfectant 
for  minutes 

Phenol 
coefficient 

2K 

5 

1'A 

10 

12,'i 

15 

Phenol 

1.90 

1.100 

1.500 
1.550 
1.600 

+ 

+ 

+ 
+ 
+ 

+ 

+ 
+ 
+ 

+ 

+ 
+ 

+ 

- 

- 

100)550 

5.5 
coefficient 

Disinfectant  "A"..  .  . 

Phenol  Coefficient  of  Some  Commercial  Disinfectants. 


Names  of  Disinfectants 

Without 
O  rganic 
Matter 

With 
Organic 
Matter 

Phenol 

Bacterol 

Carbolene 

Chloro-naphtholeum 

Cremoline 

Creolin 

Crude  Phenol 

2. 

1.58 
1.36 
6.06 
1.26 
3.25 
2.75 
3.00 
2.12 
2.62 
0.9 

2. 

1.34 
.65 

3.21 
.69 

2.90 

2.63 

Compound  solution  of  cresol 

1.87 

Lysol 

Tricresol 

Electrozone 

1.57 
2.50 

Phenol  Sodique. — A  20  per  cent  solution  of  phenol  sodique  did 
not  kill  B.  typhosus  within  15  minutes.  The  determination  of 
the  coefficient  is  impracticable. 

Piatt's   Chlorides. — In   diluted    form,    required    10    minutes   in 


ANTISEPTICS  107 

which  to  kill  B.  typhosus.  Therefore  the  coefficient  was  indetei'- 
minable. 

Dioxygen. — The  determination  of  the  coefficient  is  impracticable. 

In  the  following  table  the  more  common  antiseptics  are  ar- 
ranged approximately  according  to  their  relative  strength.  It 
must  be  borne  in  mind,  however,  that  the  absolute  strength  of 
these  antiseptics  can  be  correctly  determined  only  by  laborious 
tests,  using  germs  of  the  same  family,  and  exposing  them  in  equal 
numbers  and  under  absolutely  equal  conditions  to  nutrient  media, 
temperature,  and  time;  in  other  words,  they  have  to  be  standard- 
ized. 

The  table  is  compiled  from  the  various  publications  of  Koch, 
Sternberg,  Miquel,  and  Kitasato. 


Antiseptics. 

Extremely  Strong  Antiseptics. 

Solution  hydrogen  dioxid.  Mercuric  clilorid.  Silver  nitrate. 

Solution   of   formaldchyd.  Chinosol.  Sublaniin. 

Very  Strong  Antiseptics. 

lodin.  Thymol.  Cresol. 

Compound  solution  of  cresol.       Creosote.  Phenol. 

Strong  Antiseptics. 

Ciipric  sulphate.  Zinc  chlorid.  Aluminum    chlorid. 

Salicylic  acid.  Chloroform.  Boric  acid. 

Medium  Strong  Antiseptics. 

Potassium  permanganate.  Quinin  sulphate.  Arsenic   trioxid. 

Alcohol.  Benzoic  acid.  Acctanilid. 

Ferrous  sulphate.  Sodium  borate. 

AVeak  Antiseptics. 

Ammonium  chlorid.  Sodium  chlorid.  Glycerin. 

The  following  table  gives  the  concentration  of  the  various  anti- 


108 


PHARMACO-THERAPEUTICS 


septics  in  which  they  can  be  utilized  in  the  mouth  according  to 
Miller  :i 


Mercuric  chlorid 1:2,000 

Benzoic  acid 1:300 

Salicylic  acid  1:300 

Hydronaphtol    1 : 1,500 

Lysol 1:200 

Phenol    1:100 

Boric  acid 1 :50 

Zinc  phenolsulphonate 1:250 

Solution  aluminum  acetate.  1:20 
Solution  hydrogen  dioxid. .  2-4:100 

Saccharin 1 :400 


Saccharin,  easily  soluble...  1:120 

Potassium   chlorate 1:40 

Potassium  permanganate. . .  1:2,500 

Thymol   1:2,000 

Eugenol 1:750 

Oil  of  cinnamon 1:400 

Oil  of  cloves 1:550 

Oil  of  eucalyptus 1:625 

Oil  of  peppermint 1:600 

Oil  of  pinus  pumillio 1:360 

Oil  of  wintergreen 1:530 


All  those  chemicals  that  are  generically  termed  "antiseptics" 
may,  for  the  sake  of  convenience,  be  grouped  under  the  following 
headings : 

1.  Salts  of  the  heavy  metals,  their  oxids,  and  their  organic 
compounds. 

2.  Acids,  alkalies,  halogens  and  their  derivatives. 
Solutions  which  evolve  nascent  oxygen. 
Antiseptics  of  the  aromatic  series. 
Antiseptics  of  the  marsh  gas  series. 
Essential  oils,  their  derivatives,  and  their  synthetic  siihsti- 


3. 

4. 
5. 
6. 

tutes 


Salts  of  the  Heavy  Metals,  their  Oxids,  and  their  Organic 
Compounds. 

The  salts  of  the  heavy  metals  form  an  important  group  of  those 
agents  that  collectively  are  termed  antiseptics.  Metals,  in  their 
pure  state,  do  not  usually  induce  any  serious  symptoms  in  the 
living  organisms  unless  their  salts  or  oxids  are  formed.  Mercury, 
copper,  silver,  etc.,  may  pass  unaltered  through  the  body  without 
causing  poisonous  effects.  The  soluble  and  insoluble  salts  of  gold, 
nickel,  or  tin  are  not  absorbed  by  the  intestines,  even  if  they  are 
administered  continuously  for  months;  hence  vessels  that  are 
made  from  such  metals,  or  that  are  covered  with  a  continuous 
coating  thereof,  and  that  are  used  for  culinary  purposes  are  free 
from  danger  if  kept  clean.     Silver  salts,  if  administered  for  a 


*  Miller:  Die  Mikroorganismen  der  Mundhohle,  1893. 


ANTISEPTICS  109 

longer  period,  may  be  absorbed  and  deposited  in  a  reduced  form 
in  the  connective  tissues,  causing  a  grayish  discoloration  of  the 
skin  (argyria).  Lead,  bismuth  and  mercury  salts  are  readily  ab- 
sorbed, and  consequently,  when  administered  in  continuous  doses, 
produce  typical  chronic  intoxications— lead  colic,  lead  palsy,  and 
mercurialism.  When  administered  in  sufficiently  large  doses,  the 
absorbable  salts  of  the  heavy  metals  cause  collapse  and  death;  in 
small  doses  they  produce  necrosis  of  the  specific  tissues,  affectnig 
primarily  the  liver  and  the  kidneys.  Certain  metals — as  mercury, 
bismuth,  iron,  etc. — are  readily  excreted  by  the  lower  bowel;  some 
metals,  as  mercury,  show  a  predilection  for  diseased  mucous  mem- 
branes. The  constant  irritation  produced  by  their  excretion 
through  the  saliva  causes  various  forms  of  stomatitis  (mercury 
and  bismuth),  and  in  cases  of  lead  salts  causes  a  deposit  of  lead 
sulphid  along  the  gingival  line,  known  as  the  "lead  line."  Some 
few  metals,  in  their  pure  state,  possess  antiseptic  action.  Accord- 
ing to  Miller,  gold,  silver,  and  mercury — and,  to  a  less  extent, 
copper,  nickel,  and  zinc — inhibit  the  growth  of  certain  forms  of 
pathogenic  micro-organisms,  while  iron,  tin,  and  lead  practically 
show  no  action.  This  antiseptic  action  is  the  result,  according  to 
Behring,  of  the  reaction  of  certain  waste  products  of  the  bacteria 
with  those  metals  that  are  capable  of  forming  small  quantities  of 
soluble  salts  and  that  diffuse  through  the  medium. 

The  salts  of  the  heavy  metals  are  principally  protoplasm  poi- 
sons, but  differ  widely  in  their  toxic  action.  In  concentrated  solu- 
tions they  may  act  as  severe  caustics,  while,  when  well  diluted, 
only  astringent  effects  are  obtained.  The  soluble  metallic  salts 
possess  an  astringent  and  nauseating,  sweetish  taste.  If  swallowed 
in  more  or  less  concentrated  solutions,  they  induce  vomiting, 
which  is  so  very  effective  with  certain  metallic  salts  that  they  are 
frequently  employed  as  reliable  emetics — as  copper  sulphate  and 
zinc  sulphate.  The  insoluble  salts  of  the  heavy  metals  do  not, 
of  course,  possess  any  germicidal  action,  or  even  produce  physio- 
logic effects — as,  for  instance,  the  insoluble  mercury  sulphid  (arti- 
ficial cinnabar).  It  should  be  remembered,  however,  that  insol- 
ubility in  water  does  not  necessarily  mean  insolubility  in  the  body 
juices.  While  the  latter  are  largely  aqueous  in  their  nature,  they 
contain  sodium  chlorid,  fatty  acids,  albumin,  etc.,  which  are  prone 


no 


PIIARMACO-THERAPEUTICS 


to  produce  soluble  double  salts  by  acting  on  the  metallic  salts. 
On  this  supposition  we  are  able  to  explain  why  the  otherwise  in- 
soluble calomel  or  bismuth  subnitrate  produce  definite  action  when 
brought  in  contact  with  the  surface  of  a  wound  or  of  the  intestines. 

The  local  action  of  the  metallic  salts  does  not  depend  upon 
the  combination  of  their  molecules  as  a  whole,  but  on  the  dissocia- 
tion of  their  ions  and  oxids  in  solution. 

To  more  readily  comprehend  the  effect  of  a  solution — the  dis- 
sociation of  a  solid,  liquid,  or  gas  in  a  solution — on  tissue,  it  is 
necessary  to  understand  the  physical  laws  governing  this  process — 


Fig.  24. 

Culture  plate  with  Pack's  cylinders  and  Abbey's  noncohesive  foil,  a,  b,  c,  d,  an- 
nealed; e,  f,  g,  not  annealed.  The  latter  did  not  allow  any  growth  to  appear  within  close 
proximity.     (Miller.) 


that  is,  the  theory  of  electrolytic  dissociation  of  Arrhenius.  When 
acids,  salts,  or  bases  are  dissolved  in  a  liquid,  usually  water,  the 
molecules  of  these  compounds  break  up  into  ions.  The  resulting 
solution  possesses  the  property  of  conducting  an  electric  current, 
and  is,  according  to  Faraday,  called  an  electrolite.  When  a  cur- 
rent passes  through  the  electrolytic  solution,  the  latter  undergoes 
certain  changes  which  are  generically  termed  electrolysis.  If,  on 
the  other  hand,  a  liquid  has  not  the  power  of  dissociating  mole- 
cules into  ions,  it  can  not  conduct  an  electric  current.  Now,  ac- 
cording to  Arrhenius,  the  conductibility  of  an  electrolyte  is  pro- 
portionately depending  on  (1)  the  number  of  ions,  (2)  the  relative 


ANTISEPTICS  111 

electric  charge  of  these  ions,  and  (3)  the  speed  of  the  ions.  Fur- 
thermore, the  resulting  ions  depend,  with  limits,  on  the  degree 
of  dilution  of  the  solution ;  a  certain  definite  dilution  dissociates 
completely  all  molecules,  and  further  dilution  merely  separates 
the  ions  farther  from  each  other.  For  example,  if  mercuric 
chlorid  (HgCL)  is  dissolved  in  water,  one  positive  ITg  ion  and 
two  negative  CI  ions  are  the  result.  All  ions  are  charged  with 
positive  or  negative  electricity.  The  negatively  charged  ions,  which 
travel  to  the  positive  pole,  are  tei'med  anions,  while  those  charged 


Fig.  25. 

Imaginary  diagrani  of  a  solution  of  incicuiic  clilorid  in  water.  The  atoms  of  niertury 
are  represented  by  the  large  circles  marked  Ilg,  the  chlorin  atoms  by  the  smaller  circles 
marked  CI.  Some  of  the  mercury  atoms  are  depicted  joined  on  the  two  chlorin  atoms 
to  form  the  salt.  Some  are  depicted  as  dissociated  "ions"  swimming  about  in  the  free 
state.  The  signs  +  and  —  attached  to  these  indicate  positive  (cations)  and  negative 
(anions)  electric  charges.     (Andrews.) 

with  positive  electricity  and  traveling  toward  the  negative  pole 
are  termed  cations.  We  may  express  the  ions  of  a  completely 
dissociated  mercuric  chlorid  solution  as  Hg-|-  and  CI — .  Water 
has,  so  far  as  known,  the  greatest  dissociating  power,  with  the 
possible  exception  of  hydrogen  dioxid.  Formic  acid,  methyl  al- 
cohol, ethyl  alcohol,  ammonia,  and  others  are,  however,  known 
to  possess  this  peculiarity  to  a  greater  or  less  degree.  The  organic 
compounds  arc  much  less  dissociated  than  the  inorganic  salts,  and 
their  ions  are  more  complex  and  are  very  little  understood  at 
present.     Although  all  definite  soluble  bodies  possess  more  or  less 


112  PH  ARM  ACO-THERAPEUTICS 

the  same  property,  at  present  we  can  speak  only  of  the  salts  of 
the  metals  and  alkalies  with  some  positive  knowledge. 

The  practical  application  of  the  above  theories  of  physical  chem- 
istry in  relation  to  the  action  of  the  metallic  salts  on  bacteria  is 
very  significant.  Our  present  knowledge  on  this  subject  is  largely 
the  result  of  experiments  of  Paul  and  Kronig,  which  were  pub- 
lished in  the  various  scientific  journals.  It  is  impossible  to  relate 
the  details  of  these  experiments,  but  the  reiteration  of  a  few 
important  points  may  serve  for  a  better  comprehension  of  the 
theory  of  electrolytic  dissociation.  As  subjects  for  experiments, 
the  authors  used  the  spores  of  anthrax  and  the  staphylococcus 
pyogenes  aureus  (a  pus  organism).  Now,  if  we  remember  that 
an  electrolyte  in  solution  is  dissociated  into  its  ions  only  in  part 
when  the  solution  is  not  infinitely  diluted,  then  the  effect  of  this 
solution  must  be  attributed  to  the  combined  actions  of  the  ions 
and  the  undissociated  molecules  present  in  it.  Paul  and  Kronig 
investigated,  first  of  all,  the  role  played  by  the  ions  of  the  undis- 
sociated molecules  in  the  disinfectant  solutions.  For  this  purpose 
the  germicidal  power  of  several  mercury  compounds,  which  are 
dissociated  to  different  degrees  in  aqueous  solutions,  was  examined. 
The  following  are  the  names  of  a  few  of  these  compounds,  ar- 
ranged in  the  order  of  their  decreasing  degree  of  dissociation : 

1.  Mercuric  chlorid,  HgClj- 

2.  Mercuric  bromid,  HgBrj. 

3.  Mercuric  cyanid,  Hg(CN)2. 

If  the  germicidal  action  of  the  halogen  ions  and  the  undisso- 
ciated molecules  is  slight  as  compared  with  that  of  the  Hg  ions, 
then  the  disinfectant  action  of  these  solutions  will  be  dependent 
in  the  main  on  the  concentration  of  the  Hg  ions — that  is,  on  the 
degree  of  dissociation  of  these  salts.  We  may  conclude  from  these 
experiments  that  the  greater  the  dissociation  of  the  mercury  com- 
pounds— that  is,  the  greater  the  number  of  mercury  ions  present 
in  the  unit  volume  of  the  given  solution — the  greater  is  its  disin- 
fectant action.  Furthermore,  it  is  not  so  much  the  concentration 
of  the  solution  alone,  but  also  the  specific  action  of  the  metallic 
salt,  that  influences  its  power  as  a  disinfectant;  if  the  cation  of 
the  metallic  salt  solution  is  very  complex,  it  is  less  concentrated 
and  consequently  less  active.  Similar  results  were  obtained  by 
Paul  and  Kronig  with  silver,  gold,  and  copper  salts.    The  in^esti- 


ANTISEPTICS  113 

gation  of  the  germicidal  action  of  acids  and  bases  has  also  brought 
to  light  many  interesting  facts.  A  few  of  the  general  conclusions 
drawn  by  the  above  named  authors  from  their  experiments  follow : 

1.  The  germicidal  action  of  solutions  of  acids  runs  parallel  to 
that  of  their  degree  of  dissociation — that  is,  parallel  to  the  number 
of  hydrogen  ions  contained  in  the  unit  volume  of  solution.  The 
anions,  and  also  the  undissociated  molecules  of  hydrofluoric,  nitric, 
and  trichloracetic  acid,  have  a  specific  toxic  effect  on  bacteria. 
This  toxicity,  when  compared  with  the  germicidal  effects  of  the 
hydrogen  ions,  becomes  insignificant  with  progressive  dilution. 

2.  The  disinfectant  action  of  bases — as  calcium,  sodium,  lith- 
ium, and  ammonium  hydroxid — runs  parallel  to  the  number  of 
free  hydroxyl  ions  contained  in  the  unit  volume  of  the  solution. 

As  is  the  case  in  every  investigation,  new  problems  arise  here 
also.  Thus,  for  example,  it  has  been  found  that,  while  such  salts 
as  corrosive  sublimate  or  silver  nitrate,  when  dissolved  in  absolute 
methyl  or  ethyl  alcohol,  have  only  slight  germicidal  powers,  cor- 
i-esponding  to  the  slight  dissociation  in  these  media,  aqueous  so- 
lutions of  these  salts  show  an  increased  disinfectant  action  when 
not  too  large  an  amount  of  these  alcohols  is  added  thereto. 

The  same  metals  attached  to  different  acids  produce  different 
effects,  depending  on  the  free  acid — that  is,  the  milder  acetic  acid 
formed  from  lead  acetate  acts  more  as  an  astringent  than  the 
stronger  nitric  acid  formed  from  lead  nitrate.  This  latter  acid 
is  highly  corrosive  and  acts  as  an  irritant.  The  actions  of  the 
various  acids  that  may  be  attached  to  one  metal  differ  widely  in 
their  therapeutic  effect — so  much  so  that  all  intermediate  stages 
from  a  mild  astringent  to  a  widespread  necrosis  may  be  produced. 
The  chlorids  and  the  nitrates  form  the  most  corrosive  acids,  the 
sulphates  are  milder,  while  the  iodids  and  bromids  are  still  less 
irritating.  The  mildest  acids  are  those  formed  from  the  organic 
salts.  The  albuminates  of  the  metals  do  not  irritate  unless  the 
poisonous  effects  of  the  metals  themselves  are  manifested. 

The  antiseptic  properties  of  the  more  important  metals  may  be 
arranged  according  to  the  following  scale,  beginning  with  the 
mildest  one:  Iron,  aluminum,  lead,  copper,  zinc,  silver,  mercury, 
etc.  The  organic  metallic  compounds  and  the  double  salts  of 
metals  form  weak  precipitates  with  albumin;  they  are  less  irri- 
tating, and  only  slowly  dissociate  and  diffuse  over  the  parts. 

Within  recent  years,  through  the  investigations  of  Bredig,  solu- 
tions of  very  pure  metals  in  water  have  been  introduced  for  anti- 


i  14  PHARMACO-THEKAPEUTICS 

septic  purposes.  These  solutions  are  variousl}^  termed  colloidal 
solutions,  pseudo-solutions,  or  simply  sols.  It  seems  paradoxical 
to  speak  of  a  water-soluble  gold,  silver,  mercurj',  etc.  It  must  be 
borne  in  mind,  however,  that  such  solutions  are  merel}^  mechanical 
suspensions  of  extremely  fine  particles  of  metal — metals  in  their 
amorphous  state  in  water.  Accordingly  these  pseudo-solutions  of 
colloids  (from  the  Latin  coUa,  glue)  are  phj'sically  different  from 
true  solutions — the  crystalloids.  ]\Iost  likel}^  the  application  of 
metals  in  their  colloidal  state  will  gain  some  prominence  in  the 
near  future.  Silver,  mercury,  copper,  iron,  and  gold  are  produced 
at  present  in  this  form,  and  no  doubt  other  metals  Avill  soon 
follow. 

For  some  time  past  chemists  have  endeavored  to  remedy  the 
irritating  properties  of  the  inorganic  metallic  salts  bj'^  preparing 
sj^nthetically  organic  metallic  compounds.  In  the  last  few  years 
quite  a  number  of  these  compounds  appeared  on  the  market, 
especially  organic  salts  of  silver  and  mercury.  Some  of  these 
compounds  give  extreme  satisfaction,  and  it  seems  safe  to  prog- 
nosticate a  good  future  for  their  general  use. 

In  general,  the  metallic  salts  have  an  acid  reaction,  and  pre- 
cipitate albumin  by  virtue  of  their  acid  or  basic  components. 
These  precipitates  differ  very  markcdlj^  in  regard  to  their  density, 
and  depend  largely  on  the  various  metallic  salts  emploj'ed.  Silvei- 
nitrate,  for  instance,  produces  a  hard,  compact,  and  dry  precipi- 
tate, which  is  definitely  localized  and  which  prohibits  the  further 
penetration  of  the  salt,  while  zinc  chlorid  produces  a  loose,  floccu- 
lent  mass  resembling  the  precipitate  of  alkalies,  and  this  sponge- 
like precipitate  does  not  prohibit  the  further  penetration  of  the 
salt  in  depth  and  width.  Hence  metallic  salts  or  other  antiseptics 
which  precipitate  albumin  or  are  interfered  with  by  the  presence 
of  organic  matter  are  more  or  less  useless  as  disinfectants — as 
bichlorid  of  mercury. 

The  antiseptic  action  of  the  metallic  salts  depends  largely  on  the 
formation  of  metallic  compounds  when  brought  in  contact  with 
proteins  or  albumins.  Usually  these  newly  formed  albuminates 
are  insoluble  in  water;  some,  however,  are  soluble  in  an  excess  of 
proteins — as  mercury — and  some  will  dissolve  in  solutions  of  neu- 
tral salts  (sodium  chlorid)  or  organic  acids  (tartaric  or  citric 
acid). 


AXTiSJa'TlCS  ll5 

When  a  solution  of  a  metallic  salt  is  applied  to  a  mucous  mem- 
brane or  to  the  surfaces  of  a  wound,  the  albumin  is  at  once  pre- 
cipitated, and  the  acid  with  which  the  metal  is  combined  is  set 
free.  Thus  a  more  or  less  dense  and  continuous  film  is  formed 
over  the  surface,  which  acts  as  a  mechanical  protective  to  the  parts 
involved,  lessening,  or  even  completely  checking,  the  further  pene- 
tration of  the  solution  into  the  deeper  structures.  The  free  acid 
acts  as  an  irritant,  which  stimulates  the  circulation  of  the  in- 
volved part,  thereby  increasing  cell  activity  and  effusion  of  ex- 
udates. The  germs  that  are  present,  being  largely  albuminous 
in  their  nature,  are  acted  on  in  the  same  manner  as  the  superficial 
cells;  they  become  coagulated  and  the  surrounding  medium  is 
changed  simultaneously  to  an  unfavorable  pabulum  for  the  new 
growth  of  micro-organisms.  The  liquid  exudates,  being  freed 
from  their  protein,  become  more  diffusible  and  are  more  easily 
absorbed,  while  the  blood  vessels  slightly  contract  and  become 
less  permeable. 

Corrosive   Mercuric    Chlorid;   Hydrargyri    Chloridum    Corro 
sivuM,  U.  S.  P. ;  Hydrargyri  Perchloridum,  B.  P. ;  HgClg- 

Etymology. — Prom  the  Greek  liydrargyros   (liquid  silver). 

Synonyms. — Mercurius  sublimatus  corrosivus,  corrosive  subli- 
mate, perchlorid  or  bichlorid  of  mercury ;  sublime  corrosif ,  F. ; 
Aetzender  Quecksilbersublimat,  G. 

Source  and  Character. — Mercuric  chlorid  is  obtained  by  sub- 
liming a  mixture  of  mercuric  sulphate,  sodium  chlorid,  and  some 
black  oxid  of  manganese.  The  latter  is  added  to  prevent  the 
formation  of  calomel. 

HgS04+2NaCl+Mn02=HgCl2+Na2S0,+Mn02. 
It  occurs  in  heavy,  colorless  rhomboid  crystals  or  masses,  odor- 
less, and  has  an  acrid  and  persistent  metallic  taste;  permanent  in 
the  air.  When  in  fine  powder  it  is  soluble  at  60°  F.  (16°  C.)  in 
13  parts  of  water,  in  3  parts  of  alcohol,  in  4  parts  of  ether,  in  2 
parts  of  boiling  water,  and  in  about  14  parts  of  glycerin.  It  is 
incompatible  with  alkalies  and  their  carbonates,  potassium  iodid, 
lime  water,  tartar  emetic,  silver  nitrate,  albumin,  soaps,  and  tannic 
acid.    It  attacks  steel  and  nickel-plated  instruments.^ 

'  Regarding  the  action  of  corrosive  sublimate  on  metallic  objects,  it  should  be  remem- 
bered that  it  not  only  causes  ^  precipitate  of  metallic  mercury  on  them,  but  the  disin 
fectant  solution  is  also  abolished   in  proportion  as  the  mercury  is  precipitated. 


lib  PHARMACO-THERAPEUTICS 

Average  Dose. — i^o  grain  (0.003  Gm.). 

Preparations. — 

Liquor  Hydrargyri  Percliloridi,  B.  P.  1  part  dissolved  in  875 
parts  of  distilled  water.    Average  dose,  %  fluidram  (2  C.c). 

Lotio  Hydrargyri  Flava;  Yellow  Wash  (Aqua  Pliagedenica). 
Mercuric  chlorid,  25  grains  (1.5  Gm.)  dissolved  in  lime  water,  16 
ounces  (473.17  C.c).    For  external  use. 

Sal  Alemhroth  {Salt  of  Wisdom).  Equal  parts  of  mercuric 
chlorid  and  ammonium  chlorid. 

Medical  Properties. — Antiseptic,  disinfectant,  caustic,  anti- 
phlogistic, specific. 

Local  Action. — Applied  on  the  unbroken  skin,  mercuric  bi- 
chlorid  produces  little  irritation  unless  kept  there  for  some  time. 
On  wounds  and  mucous  surfaces,  weak  solutions  are  antiseptic  and 
disinfectant;  if  concentrated,  they  are  caustic.  Solutions  are 
readily  absorbed,  and  they  may  produce  poisonous  effects.  Mer- 
curic chlorid,  like  all  metallic  salts,  coagulates  albumin  and  com- 
bines with  the  protoplasm  of  the  cells.  This  precipitated  albumi- 
nate of  mercury  is,  however,  soluble  in  an  excess  of  albumin  or  in 
sodium  chlorid  solutions.  For  the  sake  of  convenience,  corrosive 
sublimate  tablets  are  now  prepared,  having  tartaric  acid,  citric 
acid,  ammonium  chlorid,  etc.,  as  a  component  to  render  the  mer- 
cury more  soluble  and  to  prevent  its  precipitation  as  an  insoluble 
compound.  (Laplace.)  Bernay's  antiseptic  tablets  are  a  con- 
venient form  for  making  extemporaneous  solutions  with  measures 
of  water  ordinarily  used.  Each  tablet  contains  l^^o  grains  of 
mercuric  chlorid  and  ^^4oo  grains  of  citric  acid.  One  tablet  dis- 
solved in  4  ounces  of  water  gives  a  1 :1,000  solution.  These  tablets 
are  frequently  colored  (red  or  blue)  with  small  quantities  of 
anilin  dyes. 

Therapeutics.— Mercuric  chlorid  is  still  extensively  used  in 
antiseptic  surgery.  For  disinfectant  purposes  a  solution  of  1 :1,000 
is  employed,  while  as  a  general  antiseptic  1 :5,000  is  quite  sufficient. 
In  dentistry  its  application  as  a  mouth  wash,  although  very  effi- 
cient, is  not  to  be  recommended;  the  superficial  epithelial  cells  of 
the  mucous  lining  of  the  mouth  are  readily  destroyed  by  its  pro- 
longed use.  As  a  disinfectant  for  putrescent  root  canals  and  for 
abscesses  and  fistulas,  a  slight  acid  solution  of  1  part  in  1,000  parts 
of  hydrogen  dioxid  solution  is  one  of  the  most  effective  agents  at 
our  command.     It  is  also  recommended  for    the    disinfection    of 


ANTISEPTICS  117 

pyorrhea  pockets  (a  glass  syringe  with  a  platinum  point  should  be 
used).  Miller  has  recommended  its  application  with  thymol  as  a 
mummifying  agent  for  pulp  stumps;  teeth  treated  in  this  manner 
usually  become  badly  discolored  (mercuric  sulphid  being  formed), 
the  color  ranging  from  a  greenish-blue  to  a  dark  blue-black.  Ad- 
ministered internally,  corrosive  sublimate,  like  all  other  mercurials, 
is  changed  to  a  double  sodium  and  mercury  chlorid,  which  is 
soluble  in  an  excess  of  sodium  chlorid.  It  enters  the  blood  very 
rapidly,  but  seems  to  have  no  direct  action  on  the  blood.  It  quick- 
ly leaves  the  blood  and  enters  the  tissues,  where  it  may  remain  in- 
definitely; here  it  manifests  its  specific  influence  on  syphilis.  As 
it  is  very  slowly  excreted,  the  secretions  of  all  the  glands  (saliva, 
milk,  sweat,  urine,  and  bile)  are  stimulated.  It  is  a  powerful 
sialogogue,  causing  an  increased  flow  of  saliva  which  contains  mer- 
cury. The  saliva  has  a  metallic  taste,  and  acts  as  an  irritant  on  the 
mucous  membrane  of  the  mouth,  which  may  result  in  a  typical 
decubital  ulceration,  known  as  mercurial  stomatitis. 

Toxicology. — If  swallowed  in  poisonous  doses,  intense  pain  in 
the  throat,  stomach,  and  bowels  is  produced,  accompanied  by 
nausea,  retching,  bloody  vomiting,  diarrhea,  cold  sweats,  and  diffi- 
cult respiration,  followed  by  convulsions  and  death.  The  treat- 
ment should  be  primarily  directed  to  relieve  the  gastro-enteritis ; 
white  of  eggs  beaten  up  with  water,  or  milk,  to  form  insoluble 
albumin  compounds,  should  be  freely  given,  or  Avheat  flour  may 
be  substituted.  The  stomach  should  be  washed  out  before  the  acid 
contents  render  the  albumin  compounds  soluble.  The  after  effects 
should  be  treated  with  opiates,  counterirritants,  and  demulcent 
drinks.  Two  grains  have  been  known  to  kill  a  man  in  half  an 
hour,  and  an  infant  died  from  the  constitutional  effects  of  corrosive 
sublimate  sprinkled  on  an  excoriated  surface. 

Antiseptic  Solution. 

B     Tablet,  antiseptic.  Bernays  No.  j 

Aq.  hydrogen,  dioxid.  flS  iv  (120  C.c.) 

M. 
Sig.:     Antiseptic  solution. 

Mercuric  Cyanid;  Hydrargyri  Cyanidum;  Hg(CN)2.  It  forms 
colorless  crystals,  without  odor  and  with  a  bitter,  metallic  taste. 
It  is  soluble  in  about  12  parts  of  water,  in  15  parts  of  alcohol,  and 


118  PHARM  ACO-THERAPEUTICS 

ill  3  parts  of  boiling  water.  Mercuric  cyanid  resembles  corrosive 
sublimate  closely  in  its  action,  but  it  is  less  active  and  much  less 
irritating.  For  this  reason  it  is  used  hypodermicallj^  in  syphilis. 
It  does  not  attack  steel  instruments  very  readily. 

Mercurol;  Mercury  Niicleinate.  It  is  an  organic  compound  of 
mercury  and  nucleinic  acid  (yeast  nuclein),  containing  about  10 
per  cent  of  metallic  mercury.  It  appears  in  the  form  of  a  brownish- 
white  powder,  soluble  in  water,  but  insoluble  in  alcohol.  It  does 
not  precipitate  albumin,  but  has  marked  bactericidal  power,  and 
possesses  the  typical  action  of  a  soluble  mercury  compound.  It  is 
used  in  1  to  2  per  cent  solutions  as  an  antiseptic. 

Suhlamin.  It  is  an  organic  mercury  compound,  which  is  chem- 
ically defined  as  mercuric  sulphate-ethylendiamin.  It  is  composed 
of  3  molecules  of  mercuric  sulphate  and  8  molecules  of  ethy- 
lendiamin,  and  contains  about  44  per  cent  of  mercury.  It  occurs  in 
white  needle-like  crystals,  Mhich  readily  dissolve  in  water,  with  an 
alkaline  reaction,  but  which  are  only  slightly  soluble  in  alcohol. 
Sublamin  is  recommended  for  the  disinfection  of  the  skin,  hands, 
etc.,  in  1 :1,000  solution.  As  it  does  not  precipitate  albumin,  it 
possesses  greater  penetrating  power  than  mercuric  chlorid,  and  is 
less  poisonous,  less  irritating,  and  more  readily  soluble  than  the 
latter  salt.  It  is  stated  that  it  does  not  attack  metallic  instruments. 
This  statement  is  not  correct ;  sublamin  attacks  metallic  surfaces, 
although  less  so  than  corrosive  sublimate. 

Sapodermin.  It  is  an  albuminate  of  mercury  in  the  form  of  a 
soap  in  which  the  mercuric  chlorid  is  incorporated  with  a  refined 
stearin  and  glj^cerin.    It  is  principally  used  for  hand  disinfection. 

Hermophenyl;  Sodio-Mercuric  Phenol  Disidplionate.  It  is  a 
very  soluble  mercuric  compound,  which  has  gained  some  reputa- 
tion as  an  antisj^philitic.  Kecently  it  has  been  recommended  as 
a  substitute  for  mercuric  chlorid  in  dentistry. 

Red  Mercuric  Oxid;  Hydrargyri  Oxiduin  Ruhrum,  U.  S.  P.,  B. 
P. ;  HgO ;  Red  Precipitate.  It  is  an  orange-red  amorphous  poAvder. 
It  is  insoluble  in  water  and  in  alcohol. 

Yellow  Mercuric  Oxid;  Hydrargyri  Oxidum  Flavum,  U.  S.  P.: 
HgO.    It  is  a  light  orange-yellow  amorphous  powder. 

Red  Mercuric  lodid;  Hydrargyri  Jodidum  Ruhrum,  U.  S.  P.. 
B.  P. ;  Hglo.  It  is  a  scarlet-red  amorphous  powder.  Average  dose 
Yjo  grain  (0.003  Gm.). 

Ycllovj  Mercuroua  lodid;  Hydrargyri  lodidum    Flavum,  U.   S. 


ANTISEPTICS  119 

P. ;  Hgl.  It  is  a  bright-yellow  amorphous  powder,  tasteless  and 
odorless.  It  is  insoluble  in  alcohol,  water,  and  ether.  Average  dose, 
y^  grain  (0.01  Gm.). 

Ammoniated  Mercury;  Hydrargyrum  Ammoniatum,  U.  S.  P. ; 
B.,  P.;  HgNHaCl;  Wliite  Precipitate.  It  is  a  white  amorphous 
powder,  without  odor  and  with  an  earthy,  metallic  taste.  It  is  al- 
most insoluble  in  water  and  alcohol. 

Bismuth  Subnitrate;  Bismuthi  Subnitras,  U.  S.  P.,  B.  P. 

White  bismuth,  magisterium  bismuthi;  sous-azotate  de  bismuth, 
F. ;  Wismutsubnitrat,  G. 

Source  and  Character. — It  is  a  Avhite  heavy  powder,  consisting 
of  a  mixture  of  bismuth  oxid,  nitrate,  and  hydrate,  and  containing 
about  80  per  cent  of  pure  bismuth  oxid.  It  is  odorless  and  almost 
tasteless,  insoluble  in  water  or  alcohol,  but  soluble  in  nitric  and 
hydrochloric  acid.  It  is  incompatible  with  potassium  iodid, 
calomel,  salicylic  acid,  tannic  acid,  and  sulphur. 

Average  Dose. — ly^  grains  (0.5  Gm.). 

Medical  Properties. — Astringent,  mildly  antiseptic  and  protec- 
tive. 

Therapeutics. — Bismuth  subnitrate  is  principally  used  as  an 
internal  astringent  in  diseases  of  the  gastro-intestinal  canal  and  as 
a  dusting  powder  on  wound  surfaces.  For  the  latter  purpose  it  is 
useful,  as  it  readily  diminishes  the  secretions  of  the  wound.  A 
number  of  fatal  poisonings  have  been  recorded  lately  in  which 
bismuth  subnitrate  was  used  in  large  quantities  as  dusting  powder 
or  in  the  form  of  Beck's  bone  paste.  (See  Plugging  of  Bone 
Cavities.)  Bismuth  poisoning  manifests  itself  in  the  mouth  by  a 
distinct  bluish-black  line  about  the  gum  margin,  salivation,  and 
swelling  of  the  gums  and  tongue.  Gangrene  of  the  soft  palate  has 
also  been  observed. 

Bismuth  subnitrate  is  used  in  the  form  of  an  unctuous  injection 
(bismuth  subnitrate,  10  parts ;  oil  of  cotton  seed  or  oil  of  sesame, 
15  parts;  spermaceti,  30  parts)  in  radioscopy.  The  liquefied  ma- 
terial is  injected  into  the  cavity,  and  the  x-ray  picture  shows  a 
deep-black  shadow  which  distinctly  outlines  the  normal  or  patho- 
logic cavity,  sinus,  etc.  Occasionally,  general  poisoning  is  observed 
with  this  bismuth  paste,  i.  e.,  the  insolnl)lc  l)ismnth  subnitrate  is 
changed  by  Ihe  tissue  fluids  into  a  solnl)lc  nitrite. 

Xcrnform:  Bismuili  Trihromplievolale;  CJ^.^O,Tir.Ji\^.     It  is  a 


120  PHARMACO-THERAPEUTICS 

fine  yellow  powder,  nearly  odorless  and  tasteless,  insoluble  in  water 
and  alcohol,  but  partially  soluble  in  weak  hydrochloric  acid.  It 
is  a  nonirritating  and  nontoxic  astringent,  and  has  been  recom- 
mended as  a  substitute  for  iodoform.  For  some  time  past  it  Avas 
much  lauded  as  a  component  of  a  root  filling  material  composed  of 
1  part  of  xeroform,  2  parts  of  zinc  oxid,  and  sufficient  eugenol  to 
make  a  stiff  paste.  Quite  a  number  of  other  bismuth  compounds — 
bismuth  subcarbonate,  bismuth  subgallate  (dermatol),  bismuth  sub- 
salicylate, etc. — are  official,  but  they  are  of  minor  importance  to 
the  dental  practitioner;  they  are  principally  employed  as  weak 
antiseptics  intended  for  the  gastro-intestinal  canal. 

As  previously  stated  (see  Salts  of  the  Heavy  Metals),  all  salts 
of  the  heavy  metals  are  antiseptics,  and  many  of  these  salts  are 
also  powerful  astringents.  Certain  metallic  salts — the  silver,  cop- 
per, and  zinc  salts — are  superseded  in  their  antiseptic  action  by 
their  astringent  qualities,  and  are  principally  employed  for  this 
purpose  in  dental  medicine.  Consequently  we  have  preferred  to 
classify  these  metallic  salts  under  the  general  heading  of  astrin- 
gents. 

The  Acids,  the  Alkalies,  the  Halogens  and  their  Derivatives. 

THE  ACIDS. 

All  inorganic  and  most  organic  acids  possess  more  or  less  anti- 
septic action.  Many  of  the  acids  act  as  astringents  when  applied 
in  a  weak  solution,  and  as  caustics  when  used  in  a  pure  state.  All 
inorganic  acids,  with  the  exception  of  phosphoric  acid,  the  chlorin 
substituting  fatty  acids,  and  many  of  the  aromatic  acids,  provided 
they  are  readily  soluble  in  water,  act  as  precipitants  of  albumin. 
The  inorganic  acids,  with  the  exception  of  boric  acid,  can  not  be 
used  as  antiseptics  in  the  oral  cavity,  as  they  attack  more  or  less 
readily  the  calcium  salts  of  the  tooth  structure.  The  mineral  acids 
are  frequently  administered  in  diluted  form  as  antiseptics  in  dis- 
turbances of  the  gastro-intestinal  canal ;  they  should  always  be  taken 
through  a  glass  tube,  to  protect  the  teeth. 

Many  of  the  organic  acids  are  classified  as  aromatic  compounds 
and  others  as  caustics,  and  consequently  they  are  discussed  under 
their  respective  headings.  (See  Antiseptics  of  the  Aromatic  Series, 
and  Caustics.) 


ANTISEPTICS  121 

Boric  Acid  ;  Acidum  Boricum,  U.  S.  P.,  B.  P. ;  H3BO3 ;  Boracic 
Acid;  Acide  Borique,  F.;  Borsaure,  G. 

Source  and  Character. — It  is  usually  prepared  from  native 
borax  (sodium  borate).  It  is  a  light,  white,  very  fine  powder, 
unctuous  to  the  touch,  or  translucent,  colorless  scales,  odorless,  and 
having  a  faintly  bitter  taste.  It  is  soluble  in  18  parts  of  water, 
15  parts  of  alcohol,  5  parts  of  glycerin,  and  readily  soluble  in  boil- 
ing water. 

Average  Dose. — 7I/2  grains  (0.5  Gm.). 

Medical  Properties. — Antiseptic  and  astringent. 

Therapeutics. — Boric  acid  is  a  mild,  nonirritating  antiseptic 
and  slight  astringent;  it  is  the  only  mineral  acid  which  does  not 
affect  tooth  structure.  In  the  form  of  a  dusting  powder,  as  a 
glycerite  or  an  ointment,  and  in  saturated  aqueous  solutions,  it  is 
widely  used  as  an  external  and,  occasionally,  internal  antiseptic. 
It  is  apparently  more  active  on  molds  and  fission  fungi  than  on 
pathogenic  bacteria.  In  the  form  of  Thiersch's  solution  it  is  of 
service  in  washing  out  the  antrum  or  other  body  cavities.  On  ac- 
count of  its  very  mild  acidity  it  is  largely  used  as  the  principal 
component  of  many  proprietary  mouth  washes.  As  a  dusting 
powder  on  large  wound  surfaces,  boric  acid  must  be  used  with  cau- 
tion, to  prevent  too  rapid  absorption.  A  few  cases  of  poisoning, 
of  which  two  have  ended  fatally,  have  resulted  from  the  too  liberal 
use  of  this  antiseptic.  Boric  acid  is  sometimes  added  to  foods  as  a 
preservative,  which  has  given  rise  to  heated  discussions  in  regard 
to  its  deleterious  effects  on  the  health  of  the  consumer.  Its  use 
for  such  purposes  is  prohibited  in  the  United  States. 

Glycerite  of  Boroglycerin;  Glyceritum  Boroglycerini,  U.  S.  P. ; 
Glyceritum  Acidi  Borici,  B.  P.  It  is  a  compound  formed  by  heat- 
ing boric  acid  in  glycerin,  which  is  then  dissolved  in  glycerin.  It 
contains  31  per  cent  of  boric  acid. 

Ointment  of  Boric  Acid;  Unguentum  Acidi  Borici,  U.  S.  P.,  B. 
P.    A  paraffin  ointment  containing  10  per  cent  of  boric  acid. 

Antiseptic  Solution;  Liquor  Antisepticus.  It  contains  2  per  cent 
boric  acid,  0.1  per  cent  benzoic  acid,  0.1  per  cent  thymol,  and  is 
flavored  with  eucalyptol  and  the  oils  of  peppermint,  wintergreen, 
and  thyme.  This  solution  is  apparently  intended  to  replace  the 
many  proprietary  compounds  of  a  similar  nature.  If  this  is  true,  it 
is  a  poor  substitute.    Its  taste  is  most  disagreeable,  and  its  combina- 


k 


122  PHARMACO-THERAPEUTICS 

tion  is  not  in  accordance  with  modern  conceptions  of  an  antiseptic 
solution.  Strictly  speaking,  liquor  antisepticns  is  a  toilet  prepara- 
tion and  has  been  dismissed  from  the  present  pharmacopeia  (1916). 

Hydrochloric   Acid;   Acidum   Hydrochlorium,   U.  S.  P.;   HCl; 
Muriatic  Acid  ;  Acide  Chlorhydrique,  F.  ;  Salzs.Xure,  G. 

It  contains  31  per  cent  by  weight  of  absolute  hydrochloric  acid. 
It  is  a  colorless,  fuming  liquid  of  a  pungent  odor  and  an  intensely 
acid  taste,  and  should  be  kept  in  glass-stoppered  bottles. 

Hydrochloric  Acid,  Diluted;  Acidum  Hydrochloricum 
DiLUTUM,  U.  S.  P.,  B.  P. 

It  contains  10  per  cent  (15.58  per  cent,  B.  P.)  of  absolute  hydro- 
chloric acid. 

Average  Dose, — 15  minims  (1  C.c),  well  diluted. 

Nitric  Acid;  Acidum  Nitricum,  U.  S.  P.,  B.  P.;  HNO^;  Acide 
AzoTiQUE,  F. ;  Salpetersaure,  G. 

It  is  a  colorless,  fuming  liquid,  of  a  very  corrosive  and  caustic 
nature,  having  a  suffocating  odor.  It  stains  the  skin  and  the  tis- 
sues a  bright  jellow,  and  is  used  as  a  xery  powerful  caustic  by 
placing  a  drop  of  the  acid  with  a  glass  rod  on  the  tissue  to  be  de- 
stroyed. It  contains  68  per  cent  (70  per  cent,  B.  P.)  by  weight 
of  absolute  nitric  acid.    It  should  be  kept  in  glass-stoppered  bottles. 

Nitric  Acid,  Diluted  ;  Acidum  Nitricum  Dilutum,  B.  P. 

It  contains  10  per  cent  (17.44  per  cent,  B.  P.)  bj'  weight  of  ab- 
solute nitric  acid. 

Average  Dose. — 30  minims  (2  C.c),  well  diluted. 

NiTROHYDROCHLORIC    AciD ;    AciDUM    NiTROHYDROCHLORICUM. 

U.  S.  p. ;  Aqua  Eegia  ;  Eau  Kegale,  F.  ;  Konigs\vasser,  G. 

It  is  formed  by  mixing  180  parts  of  nitric  acid  with  820  parts  of 
hydrochloric  acid.  It  has  been  suggested  to  use  this  mixture  as  a 
substitute  for  sulphuric  acid  in  the  opening  of  root  canals,  accord- 
ing to  Callahan 's  suggestion. 

NiTROHYDROCHLORIC  AciD,  DILUTED;  AciDUM  NiTROHYDROCHLORICUM 

Dilutum,  U.  S.  P.,  B.  P. 

It  is  formed  by  mixing  40  parts  of  nitric  acid  with  ISO  parts  of 
hydrochloric  acid,  and  with  enough  water  to  make  1,000  parts  (6 


ANTISEPTICS  123 

parts  nitric  acid,  8  parts  hydrochloric  acid,  and  50  parts  distilled 
water,  B.  P.). 

Average  Dose. — 15  minims  (1  C.c). 

Sulphuric  Acid;  Acidum  Sulphuricum,  U.  S.  P.,  B.  P.;  H.,SO, ; 
Oil  op  Vitriol  ;  Acide  Sulphurique,  F.  ;  Schwefelsaure,  G. 

It  is  a  colorless,  oily  liquid,  containing  92.5  per  cent  (98  per 
cent,  B.  P.)  by  weight  of  absolute  sulphuric  acid.  It  is  very  caustic 
and  corrosive,  often  causing  charring  of  the  tissues  and  leaving  a 
coal-black  slough.  It  should  be  kept  in  well-stoppered  bottles. 
Sulphuric  acid  in  50  per  cent  solution  has  been  recommended  by 
Callahan^  as  a  means  of  opening  and  enlarging  obstructed  root 
canals;  it  is  very  useful  for  such  purposes.  The  acid  may  be  car- 
ried to  the  root  canal  with  a  platinum  probe  or  on  a  fcAV  fibers  of 
asbestos  wrapped  about  the  probe.  It  is  Avell  to  remember  that  in 
diluting  pure  sulphuric  acid  the  acid  must  be  added  in  a  thin 
stream  to  the  water  with  constant  stirring,  to  avoid  spluttering 
and  overheating  of  the  mixture. 

Sulphuric  Acid,  Diluted;  Acidum  Sulphuricum  Dilutum, 
U.  S.  P.,  B.  P. 

It  contains  10  per  cent  (13.65  per  cent,  B.  P.)   of  absolute  sul- 
phuric acid. 
Average  Dose. — 30  minims  (2  C.c),  well  diluted. 

Sulphuric  Acid,  Aromatic;  Acidum  Sulphuricum  Aromaticum, 

U.  S.  P.,  B.  P. ;  Elixir  of  Vitriol  ;  Elixir  Vitriolique,  F.  ; 

Aromatische  Schwefelsaure,  G-. 

It  is  an  alcoholic  solution,  flavored  with  ginger  and  cinnamon, 
containing  20  per  cent  (8  per  cent,  B.  P.)  of  absolute  sulphuric 
acid,  partly  in  the  form  of  ethyl-sulphuric  acid.  It  is  employed 
as  a  caustic,  styptic,  and  antiseptic,  and  is  much  lauded  in  the 
treatment  of  bone  diseases.  Since  the  introduction  of  phenol- 
sulphonic  acid  it  has  been  largely  superseded  by  the  latter  com- 
pound. 

.\vKHAGE  Dose. — 15  minims  (1  (^.c.),  Avell  diluted. 

'Callahan:   Proceedings  Ohio  State  Dental  Society,  1894. 


124  PHARMACO-THERAPEUTICS 

Phenolsulfonic   Acid;   Acidum   Phenolsulfonicum ;    CgHeSO^; 

SULFOCARBOLIC     AciD ;     SULFOPHENOL ;     AciDE     PhENOLSULPHON- 

iQUE,  F. ;  Phenolschwefelsaure,  G. 

Source  and  Character. — When  phenol  is  treated  with  sulfuric 
acid,  an  acid  radical  is  substituted  for  an  H  in  the  CgHsOH  of  the 
phenol,  and  a  new  compound  is  formed  which  is  known  as  phenol- 
sulfonic or  sulfo-carbolic  acid.  Depending  upon  the  mode  of  pro- 
cedure, theoretically  three  types  of  phenol-sulfonic  acid  may  be 
obtained — the  ortho,  the  meta,  and  the  para  acid.  By  treating 
phenol  directly  with  sulfuric  acid,  only  the  ortho  or  the  para  acid 
is  formed,  while  the  production  of  the  meta  acid  requires  a  more 
complicated  procedure.  The  ortho  acid  is  formed  when  phenol 
and  sulfuric  acid  are  brought  together  at  a  low  temperature,  while 
by  subjecting  this  same  mixture  to  prolonged  heating  the  pure  para 
acid  is  formed.  The  various  acids  thus  obtained  always  contain  a 
variable  small  amount  of  free  sulfuric  acid.  Phenolsulfonic  acid 
(the  ortho  or  the  para  acid)  is  a  syrupy,  yellowish  liquid,  becoming 
darker  with  age  and  having  a  pronounced  acid  reaction.  It  is 
readily  soluble  in  water,  alcohol,  and  glycerin,  but  insoluble  in 
ether,  chloroform,  and  some  oils.  It  is  practically  odorless,  or  only 
feebly  so,  resembling  phenol.  It  should  be  kept  in  glass-stoppered 
bottles,  protected  from  light. 

Medical  Properties. — Antiseptic  and  caustic. 

Therapeutics. — Phenolsulfonic  acid  was  introduced  into  chem- 
istry some  forty  years  ago  by  Laplace  and  Kekule,  and  since  that 
time  Annesen,  Fraenkel,  Vigier,  Serrant,  Hueppe,  Schneider,  and 
others  have  worked  out  its  therapeutic  value.  It  was  soon  found, 
however,  that  it  possessed  no  demonstrable  advantage  over  sulfuric 
acid,  hence  it  was  quickly  discarded  by  the  medical  profession. 
Dentistry  owes  its  reintroduction  principally  to  Buckley,  Cook  and 
MaWhinney.  When  phenolsulfonic  acid  is  applied  in  weak  aque- 
ous solutions  it  acts  primarily  as  an  antiseptic;  in  concentrated 
form  it  is  a  caustic.  Solutions  in  alcohol  or  glycerin  largely 
nullify  these  effects. 

The  action  of  phenolsulfonic  acid  may  be  defined  as  being  anti- 
septic in  a  weak  solution  and  caustic  when  applied  in  a  concen- 
trated solution.  Incidentally  it  acts  as  an  astringent  on  account  of 
its  sulfuric  acid  content.  From  the  very  nature  of  the  composition 
of  phenolsulfonic  acid,  its  primary  action  on  living  soft  tissue  mani- 
fests itself  as  a  protoplasm  poison,  i.  e.,  it  precipitates  the  proteins. 


ANTISEPTICS  125 

forming  an  eschar  which  is  ultimately  cast  off.  When  brought  into 
contact  with  bone  or  tooth  structures  its  action  depends  largely 
upon  the  nature  of  its  composition.  The  ortho  acid  acts  purely  as  a 
rapid  decalcifier,  leaving  the  swelled  organic  matrix  of  the  bone  or 
tooth  substance  intact,  while  the  para  acid  acts  somewhat  like  sul- 
furic acid,  i.  e.,  it  destroys  the  structures  in  toto,  only  to  a  much 
milder  degree.  Sulfuric  acid  acts  principally  as  a  caustic.  It  pre- 
cipitates the  proteins  of  the  soft  tissues,  forming  a  white  eschar 
which  ultimately  becomes  black  by  carbonization.  When  brought 
in  contact  with  bone  or  tooth  structure  it  kills  the  organic  content, 
removes  the  water  present,  breaks  up  the  organic  material  by  form- 
ing water  from  the  liberated  oxygen  and  hydrogen,  leaving  ul- 
timately nothing  but  carbon.  The  calcium  salts  are  simultaneously 
dissolved  and  removed  with  the  organic  matrix.  Its  action  is  much 
more  rapid  on  dead  bone  or  tooth  structure.  In  regard  to  the  anti- 
septic action  of  phenolsulfonic  acid,  the  experimental  work  of 
Hueppe,  Vigier,  Serrant,  Schneider,  and  others  has  clearly  demon- 
strated the  important  fact  that  of  the  three  types  of  phenolsulfonic 
acid,  the  ortho  acid  is  the  most  active,  and  the  para  acid  is  the 
weakest,  while  the  meta  acid  stands  intermediate  between  the  two. 
According  to  Schneider,  the  ortho-phenol -sulfonic  acid  is  three 
times  as  effective  as  the  para  acid.  A  one  per  cent  solution  of  ortho- 
phenol-sulfonic  acid  is  equal  in  its  antiseptic  power  to  a  1  per  cent 
solution  of  phenol,  while,  consequently  a  1  per  cent  solution  of  para 
acid  is  approximately  three  times  less  effective.^  The  phenol  con- 
tent of  the  phenol-sulfonic  acid  plays  no  active  part  in  the  thera- 
peutic effect  of  the  latter ;  the  phenol  is  changed  into  a  more  or  less 
inert  compound  by  the  formation  of  the  sulfon  radical. 

Ortho-  and  para-phenol-sulfonic  acid  may  be  advantageously  dis- 
pensed with  in  dental  therapeutics. 

For  many  years  past,  sulfuric  acid  has  been  used  as  a  true  bone 
solvent  (caustic)  in  general  surgery,  and  it  has  been  employed  with 
marked  success  for  the  same  purposes  in  dental  surgery.  Its  great- 
est benefits,  however,  are  derived  from  its  application  for  the  pur- 
pose of  opening  and  enlarging  root-canals,  and  incidentally  for  the 
destruction  of  pulp  remnants  present  in  these  canals.  Callahan,^ 
in  1893,  advocated  it  for  such  purposes,  and  to  him  the  dental  pro- 
fession is  greatly  indebted  for  having  introduced  this  chemic  pro- 
cedure into  operative  dentistry,  marking  a  distinct  step  of  progress. 

>Prinz:  Dental  Cosmos,  1912,  p.  397.      'Callahan:  Ohio  Denial  Journal,  January,  1894. 


126  PHAKM  ACO-THKKAPKUTICS 

Phosphouig  Acid;  Acidum  Phosphoricum,  U.  S.  P.;  Acidum  Phos- 

PHORICUM   CONCENTRATUM,  B.   P.  ;  H3PO4  ;   AciDE  PhOSPHORIQUE, 

F. ;  Phosphorsaure,  G. 

It  is  a  colorless  liquid,  of  syrupy  consistency,  containing  85  per 
cent  (66.3  per  cent,  B.  P.)  by  weight  of  absolute  orthophosphorie 
acid.  It  is  colorless  and  has  a  strongly  acid  taste.  It  should  be 
kept  in  glass-stoppered  bottles. 

In  commerce  three  kinds  of  phosphoric  acid  are  met: 

Orthophosphorie  acid,  H3PO4. 

Metaphosphoric  acid,  HPOg  (glacial  phosphoric  acid). 

Pyrophosphorie  acid,  H^P^O-  (white,  hygroscopic,  glassy  masses). 

Metaphosphoric  acid  is  used  as  a  component  of  the  so-called  oxy- 
phosphate  of  zinc  dental  cements.  A  satisfactory  acid  for  dental 
cement  powders  may  be  prepared  as  follows:  1  ounce  (30  Gm.) 
pure  zinc  phosphate,  20  ounces  (600  Gm.)  glacial  phosphoric  acid 
in  sticks,  and  10  ounces  (300  Gm.)  distilled  water,  all  quantities  by 
weight,  are  placed  in  a  glass-stoppered  bottle,  and  set  aside  in  a 
moderately  warm  place  and  occasionally  shaken  until  the  solution 
is  completed.  The  acid  is  then  filtered  through  a  cone  of  glass 
wool  placed  tightly  into  the  neck  of  a  glass  funnel.  The  first 
portions  of  the  filtrate  are  returned  to  the  funnel  until  the  solution 
runs  off  perfectly  clear.  The  acid  is  immediately  transferi-ed  to 
small  dry  glass  bottles  and  tightly  corked.  If  the  cement,  when 
mixed  with  this  acid,  hardens  too  quickly,  the  latter  may  be  slightly 
concentrated  on  a  sand  bath ;  if  the  cement  sets  too  slowly,  a  very 
small  quantity  of  distilled  water  should  be  added  to  the  acid.  Oc- 
casionally it  will  be  found  that  the  last  part  of  the  acid  gives  poor 
results  in  mixing  the  cement ;  it  is  then  best  to  discard  the  fluid  in- 
stead of  trying  to  remedy  the  evil. 

Phosphoric  Acid,  Diluted;  Acidum  Phosphoricum  Dilutum,  U. 

S.  P.,  B.  P. 

It  contains  10  per  cent  (13.8  per  cent,  B.  P.)  by  weight  of  ortho- 
phosphorie acid. 
Average  Dose. — 30  minims  (2  C.c.)  well  diluted. 

THE  ALKALIES. 

The  antiseptic  action  of  the  alkalies  depends  principally  on  their 
power  of  disorganizing  albumin  by  dissolution.     The.y  nvo,  there- 


ANTISEPTICS  .  ]27 

fore,  closely  related  to  the  caustics.  The  alkali  salts  which  liberate 
oxygen  or  halogens  during  their  dissociation — sodium  dioxid, 
sodium  fluorid,  etc. — act  principally  through  their  negative  ions. 
The  hydrates  of  the  alkalies  are  the  strongest  and  the  carbonates  are 
the  weakest  antiseptics  of  this  group.  The  soaps  (alkaline  oleates) 
are  weak  antiseptics;  they  act  principally  as  detergents  by  virtue 
of  their  solvent  power  on  fats,  etc.  Soaps  are  often  combined  with 
specitic  antiseptics  (formaldehyd,  phenol,  tar,  etc.),  and  then  they 
become  important  therapeutic  agents  in  dermatology^  Liquid  soap, 
containing  alcohol  with  the  addition  of  an  active  antiseptic,  is  a 
valuable  hand  disinfectant ;  it  is  to  be  preferred  for  the  operating 
room  over  the  ordinary  cake  soap.  Lime,  in  the  form  of  freshly 
slacked  lime,  or  milk  of  lime,  is  a  powerful  disinfectant  for  excreta, 
provided  it  is  used  in  at  least  20  per  cent  solutions.  Its  action  is 
decidedly  more  powerful  when  combined  with  chlorin  (chlorinated 
lime) .  Sodium  and  potassium  bicarbonate  can  not  be  classed  as  anti- 
septics; sodium  chlorid,  in  a  1  per  cent  solution  (physiologic  salt- 
solution),  heated  to  body  temperature,  may  be  used  as  a  temporary 
mouth  Avash  when  an  absolute,  neutral,  mild  antiseptic  lotion  is  re- 
quired. Ammonia  is  a  weak  antiseptic;  its  powerful  irritating 
properties  (see  Irritants  and  Counterirritants)  prohibits  its  use  for 
antiseptic  purposes.  The  hydroxids  of  potassium  and  sodium  are 
powerful  caustics;  they  are  occasionally  employed  as  antiseptics  in 
the  treatment  of  gangrene  of  the  pulp.  (See  Decomposition  of  the 
Tooth  Pulp  and  its  Treatment.) 

Sodium  Borate  ;  Sodii  Boras,  U.  S.  P. ;  Borax,  B.  P. ; 
Na3,0,+10HoO ;  Borax,  F.,  G. 

Source  and  Character. — It  forms  colorless  crystals  or  a  white 
powder,  odorless,  and  having  a  sweetish,  alkaline  taste.  It  is  sol- 
uble in  20  parts  of  water,  very  soluble  in  glycerin,  but  insoluble  in 
alcohol.    To  a  nonluminous  flame  it  imparts  an  intense  yellow  color. 

Average  Dose. — 7I/2  grains  (0.5  Gm.). 

Therapeutics. — Sodium  borate  is  a  mild  antiseptic,  and  is  free- 
ly employed  in  diseases  of  the  mucous  membranes.  It  is  an  im- 
portant component  of  the  widely  used  Dobell's  solution.  Combined 
with  solutions  of  formaldehyd,  it  is  found  to  be  very  serviceable 
for  the  sterilization  of  metallic  instruments. 


128  pharmaco-therapeutics 

Dobell's  Solution  (N.  F.). 

1}     Sodium  borate  gr.  cxx   (8  Gm.) 

Sodium  bicarbonate  gr.  cxx  (8  Gm.) 

Phenol,  liquid  gr.  xxiv  (1%  C.c.) 

Glycerin  flS  sa  (15  C.c.) 

Water  fl3  xvi  (500  C.c.) 

Sterilizing  Fluid  for  Instruments. 

B     Solution  of  formaldehyd         3  v  (20  C.c.) 
Sodium  borate  3  iii  (12  Gm.) 

Water  3  x  (40  C.c.) 

SoAP;  Sapo,  U.  S.  p.;  Sapo  Duras,  B.  P.;  Hard  Soap;  Castile 
Soap  ;  Savon,  F.  ;  Seife,  G. 

It  is  prepared  from  sodium  hydroxid  and  olive  oil. 

Soft  Soap;  Sapo  Mollis,  U.  S.  P.,  B.  P. ;  Green  Soap.  It  is  a 
soft,  unctuous,  brownish-green  soap  made  from  potassium  hydroxid, 
linseed  oil,  and  alcohol. 

Curd  Soap;  Sapo  Atmnalis,  B.  P.  It  is  a  hard  soap  made  from 
sodium  hydroxid  and  some  purified  animal  fat  containing  chiefly 
stearin. 

A  very  serviceable  liquid  soap  for  the  operating  room,  which  may 
be  readily  made  in  large  quantities  on  an  economical  basis,  is,  ac- 
cording to  WilbertV  formula,  prepared  as  follows: 

H.     Sodium  hydrate  3  viij   (32  Gm.) 

Potassium  hydrate  3  L   (200  Gm.) 

Cottonseed  oil  3  C  (400  Gm.) 

Alcohol  •     3  L  (200  C.c.) 

Distilled  water  3  D  (2000  C.c.) 

In  a  suitable  container,  preferably  a  glass-stoppered  bot- 
tle, dissolve  the  sodium  hydrate  and  the  potassium  hydrate 
in  250  parts  of  distilled  water,  add  the  alcohol,  and  then  add 
the  cottonseed  oil  in  3  or  4  portions,  shaking  vigorously 
after  each  addition.  Continue  to  agitate  the  mixture  occa- 
sionally until  saponification  has  been  completed;  then  add 
the  remaining  portion  of  distilled  water  and  mix.  The  only 
precautions  that  are  at  all  necessary  is  to  use  U.  S.  P.  grade 
of  ingredients,  and  to  be  sure  that  saponification  is  com- 
plete before  adding  the  remaining  portion  of  the  distilled 
water. 


'Wilbert:   American  Druggist,   1908,  p.   139. 


ANTISEPTICS 


129 


The  addition  of  2  per  eent  solution  of  formaldehyd  increases  the 
antiseptic  effect  of  this  liquid  soap  very  markedly.     Liquid  soap 


Fig.  26. 
Liquid  soap  dispenser. 


dispensers  are  at  present  available  in  the  market,  which  materially 
facilitate  the  ready  use  of  this  toilet  necessity. 


L 


THE  HALOGENS  AND  THEIR  DERIVATIVES. 

The  antiseptic  value  of  the  halogens — bromin,  chlorin,  fluorin, 
and  iodin — depends  on  the  chemic  reaction  which  ensues  when  they 
are  brought  in  contact  with  albumin;  they  substitute  their  own 
atoms  for  the  hydrogen  atoms  of  the  albumin  molecule  and  thereby 
destroy  the  latter.  Incidentally,  halogen  acids  are  formed  which 
act  as  precipitants  of  albumin.  The  halogens  are  rarely  used  as 
antiseptics  or  disinfectants  in  solid  form  or  as  gases ;  they  act  only 
in  the  presence  of  moisture.  In  aqueous  solution  they  are  power- 
ful disinfectants,  and  are  used  as  such,  especially  chlorin,  on  a 
large  scale.  Bromin  or  its  compounds  and  fluorin  are  not  employed 
as  antiseptics.  Sodium  fluorid  possesses  powerful  antiseptic  prop- 
erties; its  use  has  been  suggested  as  an  addition  to  tooth  powders 
(see  Preparations  for  the  Mouth  and  Teeth),  and  it  is  largely  em- 
ployed in  the  industries  for  checking  fermentation  in  manufactur- 
ing yeast,  in  distilleries,  breweries,  etc.    Head  has  recently  intro- 


1 30  PHARMACO-THERAPEUTICS 

duced  an  ammonium  bifluorid  as  a  "tartar  solvent."  (See  Urie 
Acid  Solvents.)  Chlorin  in  the  form  of  chlorinated  lime  has  found 
a  wide  field  of  application  as  a  disinfectant  for  dejecta,  bedding, 
etc.,  and  incidentally  as  a  bleaching  agent.  (See  Bleaching 
Agents.)  lodin  in  compound  aqueous  solutions  and  as  iodin  tri- 
ehlorid  possesses  powerful  antiseptic  properties;  at  one  time  the 
latter  compound  was  i-eeommendcd  as  an  antiseptic  for  root  canal 
treatment,  but  it  has  never  come  into  general  use.  Tincture  of 
iodin  applied  as  an  antiseptic  has  become  quite  prominent  within 
the  last  few  j^ears.  Surgeons  are  utilizing  the  powerful  antiseptic 
properties  of  iodin  in  alcoholic  solution  with  marked  success  as  a 
means  of  asepticizing  the  skin  prior  to  an  incision.  The  technique 
is  very  simple.  The  field  of  operation  is  cleansed  in  the  ordinary 
way  with  hot  water  and  soap,  and  the  tincture  of  iodin  is  painted 
over  the  surface  within  the  region  of  the  incision  in  the  form  of  a 
broad  band.  The  iodin  solution  keeps  the  bacteria  and  their  germs 
fixed  to  the  surface  during  the  operation.  The  application  of  this 
method  for  operations  in  the  mouth  deserves  to  be  recommended. 
Aseptic  wounds  that  heal  by  first  intention  often  fail  to  give  the 
clean  linear  cicatrix  aimed  at  by  both  surgeon  and  patient.  Aftei- 
the  sutures  are  removed,  the  margin  of  the  incision  often  leaves 
small  cuneiform  fissures,  which  finally  result  in  an  irregular  scai\ 
To  stimulate  rapid  cell  proliferation,  the  slightly  irritating  prop- 
erty of  tincture  of  iodin  is  useful.  The  action  of  its  alcoholic  com- 
ponent is  responsible  for  the  light  form  of  hyperemia  which,  to- 
gether with  the  iodin,  influences  the  healing  of  the  wound  most 
markedly,  and  usually  a  clean,  small  scar  results.  The  tincture 
should  be  applied  once  a  day  for  four  or  five  days  following  the 
removal  of  the  stitches.  Iodin  achieved  its  greatest  triumph 
through  its  many  aromatic  compounds,  of  which  iodoform  is  the 
typical  representative.  The  various  solutions  of  iodin  are  prin- 
cipally employed  as  irritants  (see  Irritants  and  Counterirritants), 
while  its  salts  are  largely  used  as  specifics  in  the  third  stage  of 
syphilis  and  to  favorably  influence  metabolism.     (See  Alteratives.) 

Iodoform  ;  Iodoformum,  U.  S.  P.,  B.  P. ;  CHI3 ;  Triiodomethan  ; 

lODOFORME,  F. ;  JODOFORM,  G. 

Source  and  Character. — It  is  usually  obtained  by  the  action  of 
iodin  on  alcohol  in  the  presence  of  an  alkali  or  alkali  carbonate.  It 
is  a  fine  lemon-yellow  powder  or  small  crystals,  possessing  a  very 


ANTISEPTICS  131 

persistent  and  penetrating  odor  and  a  disagreeable  taste.  It  is 
practically  insoluble  in  water,  but  soluble  in  about  50  parts  of  alco- 
hol, 6  parts  of  ether  and  fixed  and  volatile  oils.  It  is  incompatible 
with  calomel,  mercuric  oxid,  silver  nitrate,  tannin,  and  balsam  of 
Peru. 

Average  Dose. — 4  grains  (0.25  Gm.), 

Medical  Properties. — Antiseptic,  alterative,  and  anesthetic. 

Therapeutics. — Iodoform  is  the  wound  antiseptic  par  excellence. 
It  has  many  objections  which  materially  limit  its  use  in  surgery. 
Iodoform,  per  se,  does  not  possess  antiseptic  properties,  in  spite 
of  its  high  iodin  component  (96  per  cent)  ;  ordinarily  it  is  not  even 
sterile.  Its  very  penetrating  and  persistent  odor,  which  invades 
everything  with  .which  it  comes  in  contact,  makes  its  use  disagree- 
able to  patient  and  practitioner  alike.  Iodoform  is  easily  decom- 
posed ;  when  it  is  dissolved  in  alcohol,  ether,  or  fatty  oils,  it  readily 
liberates  free  iodin.  The  secretions  of  a  purulent  wound  contain 
large  quantities  of  fatty  substances  which  dissolve  iodoform, 
especially  when  air  is  excluded.  Iodin  in  statu  nascenti  acts  as  a 
powerful  antiseptic.  Certain  bacteria — tetanus,  tubercle  bacillus, 
etc. — produce  iodin  reducing  substances;  they  are,  therefore, 
readily  destroyed  by  iodoform.  The  products  of  bacterial  activity 
are  oxidized  by  iodoform,  and  hence  it  acts  as  a  deodorant.  Its 
slightly  irritating  properties  stimulate  cell  proliferation  and  reduce 
the  migrating  power  of  the  leucocytes.  On  irritable  skin  it  is  liable 
to  cause  various  exanthematous  eruptions.  When  larger  quantities 
of  iodoform  are  quickly  absorbed,  they  produce  specific  intoxica- 
tion ;  as  the  iodoform  action  is  better  understood,  intoxications  are 
rare  at  present. 

Iodoform  is  a  sovereign  remedy  to  keep  clean,  fresh  wounds 
aseptic  and  to  check  wound  secretions.  In  abscess  cavities  and  on 
ulcerating  surfaces,  or  in  regions  which  are  easily  infected  from 
their  surroundings — the  mouth — it  acts  as  an  extremely  service- 
able prophylactic.  It  quickly  clears  up  and  deodorizes  a  foul 
wound ;  it  is  slightly  anesthetic  and  favors  granulation. 

The  opinions  regarding  the  use  of  iodoform  in  dentistry  are 
divided.  Some  practitioners  have  lauded  it  very  highly,  especially 
as  an  excellent  antiseptic  in  the  treatment  of  gangrenous  pulps, 
while  others  condemn  it  absolutely.  A  wrong  conception  regarding 
its  action  is  probably  responsible  for  these  diametrically  opposed 
views.    As  a  component  of  a  devitalizing  paste  it  has  no  place,  and, 


132  PHARMACO-THERAPEUTICS 

since  we  have  more  powerful  antiseptics  for  the  treatment  of  gan- 
grenous pulps,  it  may  be  readily  dispensed  with  for  such  purposes. 
In  the  form  of  a  5  or  10  per  cent  moist  gauze  it  is  superior  to  any 
other  known  iodin  preparation  for  the  dressing  of  foul  ulcers, 
deep-seated  pockets,  purulent  antra,  certain  disturbances  arising 
from  the  difficult  eruption  of  a  lower  third  molar,  etc.  For  the 
treatment  of  the  purulent  stages  of  pyorrhea,  iodoform  as  a  paste 
or  an  emulsion  is  still  employed  by  many  practitioners.  As  a  com- 
ponent of  a  permanent  root  filling  it  is  favored  by  many,  although 
it  is  difficult  to  understand  what  purpose  it  should  serve  in  this  con- 
nection. 

To  overcome  the  disagreeable  odor  of  iodoform,  admixtures  of 
cumarin  (the  odoriferous  principle  of  the  tonka  bean),  ground 
coffee  beans,  thj^mol,  menthol,  etc.,  have  been  suggested,  but  they 
possess  very  little  practical  value.  Whenever  the  odor  of  iodoform 
is  positively  removed,  its  composition  is  chemically  altered  and  its 
therapeutic  action  is  largely  destroyed.  To  overcome  the  many 
drawbacks  of  iodoform,  chemists  have  endeavored  to  create  iodin 
compounds  which  are  free  from  these  objections.  So  far  no  per- 
fect substitute  has  been  produced,  although  a  few  of  the  more  re- 
cent compounds  answer  the  purpose  fairly  well.  An  early  repre- 
sentative is  iodol.  It  is  apparently  less  readily  decomposed  than 
iodoform,  and  is  little  used  at  present.  Aristol — thymol  iodid — has 
been  widely  employed  for  some  time ;  it  is  very  readily  decomposed, 
but  its  iodin  component  is  materially  less  than  that  of  iodoform. 
Sozoiodolates  of  potassium,  sodium,  and  zinc  have  been  prepared ; 
the  latter  salt  has  been  quite  extensively  used  in  the  past. 
Nosophen,  antinosin,  and  entoxin  are  trade  names  given  to  iodin 
compounds  of  phenol-phthalate,  while  europhen  is  a  complex 
preparation  of  cresol  and  iodin.  Again,  iodin  compounds  of  al- 
bumin have  been  created ;  iodalbin  and  iodof ormogen  are  examples 
of  the  more  important  representatives  of  this  group.  Recently  a 
compound  of  iodin  with  quinolin  as  a  base  has  been  introduced  as 
a  substitute  for  iodoform  under  the  name  of  vioform ;  from  all  ap- 
pearances it  seems  to  be  at  present  quite  a  favorite  with  the  sur- 
geons. It  is  successfully  employed  in  the  mouth  in  all  those  con- 
ditions where  iodoform  is  indicated. 

Iodol  ;  Iodolum  ;  C4I4NH ;  Tetraiodopyrrol. 
It  is  a  light  grayish-brown  powder,  without  odor  or  taste,  in- 


ANTISEPTICS  133 

soluble  in  water,  but  soluble  in  alcohol,  chloroform,  and  ether.    It 
contains  about  89  per  cent  of  iodin. 
Average  Dose. — 4  grains  (0.25  Gm.). 

Thymol  Iodid  ;  Thymolis  Iodidum,  U.  S.  P. ;  C20H24O2I2 ; 

DiTHYMOL-DlIODID  ;   ArISTOL. 

It  is  a  light  reddish-yellow  bulky  powder,  with  a  slight  aromatic 
odor,  containing  45  per  cent  of  iodin.  It  is  insoluble  in  water  and 
glycerin,  but  readily  soluble  in  alcohol,  chloroform,  ether,  and 
volatile  and  fatty  oils.  In  the  form  of  an  oily  solution  it  is  used 
as  a  substitute  for  the  tincture  of  iodin  or  the  solutions  of  iodin  in 
fatty  oils.     (See  Irritants  and  Counterirritants.) 

EuropJien;  Diisoliutyl  Cresol  Iodid.  It  forms  a  yellow,  volumi- 
nous powder,  containing  28  per  cent  of  iodin  and  having  a  faint, 
saffron-like  odor.  It  is  insoluble  in  water  and  in  glycerin,  but 
readily  soluble  in  alcohol,  ether,  chloroform,  and  volatile  and  fatty 
oils.    It  resembles  thymol  iodid  very  closely  in  its  action. 

Vioform;  lodocJiloroxyquinolin;  Nioform.  It  is  a  very  volu- 
minous light-yellow  powder,  practically  odorless,  and  insoluble  in 
water,  but  slightly  soluble  in  alcohol.  It  may  be  sterilized  without 
decomposition.  Vioform  contains  41.57  per  cent  of  iodin.  It  is 
nontoxic  and  nonirritant,  and  it  is  claimed  to  be  an  ideal  sub- 
stitute for  iodoform.  It  deserves  to  be  recommended  for  dental 
purposes. 

A  compound  known  as  loretin  has  recently  been  introduced  as 
an  iodoform  substitute;  it  is  closely  related  to  vioform. 

Iodoform  Bone  Plombe. 

IJ     Iodoform  3  v  (20  Gm.) 

Oil  of  sesame  flS  j  (30  C.c.) 

Spermaceti  5  ii  (60  Gm.) 

Iodoform  Paste. 

Iodoform  powder  is  mixed  with  5  per  cent  phenol  solution ;  after 
24  hours  the  supernatant  fluid  is  poured  off,  and  the  iodoform  is 
mixed  with  lactic  acid  to  a  thick  paste.  This  paste  is  used  for 
the  treatment  of  purulent  pockets,  etc.,  about  the  mouth. 

The  odorless  vioform  may  be  substituted  for  iodoform  in  the 
above  preparations. 


1 34  PHARMACO-THERAPEUTICS 

Chlorinated  Lime  ;  Calx  Chlorinada,  U.  S.  P.,  B.  P.    Bleaching 
Powder  ;  Sous  Chlorure  de  Chaux,  F.  ;  Chlorkalk,  G. 

Chlorinated  lime  is  often  improperly  called  chlorid  of  lime.  It 
is  a  mixture  of  calcium  hypochlorite,  calcium  chlorid,  lime,  and 
water,  and  it  should  contain  not  less  than  35  per  cent  of  available 
chlorin.  It  is  a  white  or  grayish-white  powder,  with  the  odor  of 
chlorin,  and  giving  off  chlorin  gas  in  the  air,  especially  in  the 
presence  of  an  acid.  It  is  only  partially  soluble  in  water.  Chlo- 
rinated lime  is  used  in  the  preparation  of  the  various  chlorinated 
solutions,  as  a  bleaching  agent,  and  as  a  disinfectant  on  a  large 
scale.  For  the  latter  purposes  it  is  best  emploj^ed  in  the  form  of 
milk  of  lime,  with  an  excess  of  acid;  it  must  be  used  liberally  if 
complete  success  should  be  insured.  As  a  deodorizer  of  the  oral 
cavity  in  the  form  of  a  tooth  powder  it  should  not  be  used. 

Preparations. — 

Liquor  Sodw  CldorinaUv,  U.  S.  P.,  B.  P.;  Solution  of  Chlori- 
nated Soda.  Labarraque's  solution  or  eau  de  Javelle.  It  is  a 
clear,  pale  green  liquid,  having  an  odor  of  chlorin  and  containing 
at  least  2.6  per  cent  (2.5  per  cent,  B.  P.)  by  weight  of  available 
chlorin.  It  readily  bleaches  vegetable  colors,  and  was  formerly 
largely  used  as  a  bleaching  agent  of  discolored  tooth  structure. 

Liquor  Calcis  Chlorinatcr,  B.  P. ;  Solution  of  Chlorinated  Lime. 
A  solution  of  chlorinated  lime,  yielding  about  3  per  cent  of  avail- 
able chlorin. 

Antiformin.  It  is  a  strongly  alkaline  solution  of  sodium  hypo- 
chlorid.  It  may  be  readily  prepared  by  mixing  equal  quantities  of 
the  official  solutions  of  soda  and  of  chlorinated  soda.  Under  the 
name  of  radicin  it  has  ])ecn  advocated  for  the  treatment  of  in- 
fected root  canals. 

Solutions  Which  Evolve  Nascent  Oxygen. 

Molecular  oxygen,  in  its  pure  state  or  mixed  with  nitrogen  and 
other  gases  in  the  form  of  air,  does  not  manifest  an  inhibitory  or 
destructive  action  on  bacteria.  For  a  long  time  chemists  have 
been  familiar  with  the  powerful  affinity  of  oxygen  in  its  nascent 
state  for  other  substances,  which  process  is  known  as  oxidation. 
Robin  has  experimentally  shown  that  the  therapeutic  effect  of  a 
substance  is  greatly  intensified  if  it  is  set  free  from  its  compound 


ANTISEPTICS  135 

in  the  organism- — if  it  is  present  in  statu  nascendi.  This  is  espe- 
cially true  of  many  of  the  oxygen  compounds. 

Nascent  oxygen  may  be  furnished  by  two  kinds  of  autoxidizers — 
one  direct  source  is  its  allotropic  form  known  as  ozone,  and  the 
other  is  represented  by  the  many  dioxids,  chiefly  hydrogen  dioxid, 
and  those  of  the  alkali  and  alkaline  earth  metals.  The  nascent 
oxygen  obtained  from  both  sources  is  based  on  the  same  principle 
of  formation : 

Ozone=0^ — 0 — 0,  or  O3,  is  split  up  in  Og-f-O  (nascent  state). 

A  dioxid/  X — 0 — 0,  or  XOg,  is  split  up  in  XO+0  (nascent 
state) . 

According  to  Nernst,  the  formation  and  the  association  of 
ozone  is  illustrated  by  the  following  equation: 

03?^0,+0 

Only  one  atom  of  the  three  atoms  of  the  ozone  molecule  enters 
into  active  or  atomic  oxygen,  the  other  two  forming  molecular  or 
inactive  oxygen.  This  very  fact  is  true  of  the  oxygen  molecule 
of  a  dioxid — one  atom  is  set  free,  while  the  other  one  remains 
combined  with  the  metal  in  the  form  of  an  oxid.  The  ozone 
molecule  and  the  dioxid  molecule  play  the  role  of  a  single  atom  of 
oxygen  in  the  reaction  of  oxidation.  The  amount  of  available 
oxygen  in  a  dioxid  depends  on  the  degree  of  superoxidation  of 
the  original  oxid.  Ozone,  as  well  as  the  dioxids,  are  endothermic 
compounds — that  is,  they  require  energy  in  the  form  of  heat  or 
electricity  for  their  formation.  They  are  comparatively  easily 
decomposed,  liberating  again  the  same  amount  of  energy  in  the 
form  of  heat  which  was  absorbed  in  their  formation.  Ozone  has, 
so  far,  been  produced  only  as  a  gas,  while  the  dioxids,  with  the 
exception  of  hydrogen  dioxid,  are  solids.  Oxygen  obtained  from 
ozone  is  usually  produced  by  electric  energy  at  the  place  of  its 
consumption ;  it  is  an  unstable  gas,  which,  for  practical  purposes, 
can  not  well  be  stored.  The  dioxids  are  usually  fairly  stable  com- 
pounds; they  furnish  any  fixed  amount  of  oxygen,  if  so  desired, 
at  any  moment,  and  are,  in  reality,  transportable  accumulators  of 
available  oxygen. 

Atomic  oxygen — oxygen  in  its  nascent  state — has  a  free  valency ; 
it  can  not  remain  in  that  state,  but  energetically  seeks  to  combine 

'  X  represents  any  metal  coniljined  with  two  atoms  of  oxygen  into  a  dioxid. 


k 


136  PHARMACO-THERAPEUTICS 

with  organic  matter.  This  powerful  affinity  for  every  oxidizable 
substance,  including  albumin,  is  known  as  oxidation,  or,  when  ac- 
companied by  heat  and  light,  as  combustion.  The  antiseptic  ac- 
tion of  the  oxygen  carrying  metals  depends  on  this  fact.  The 
negative  nascent  oxygen  which  is  set  free  during  ionization  of 
the  metallic  dioxids  is  very  little  irritating  to  the  soft  tissue,  while 
certain  of  the  positive  metallic  ions  act  as  caustics ;  this  factor  pro- 
hibits the  use  of  the  latter  compounds  as  wound  antiseptics — 
sodium  dioxid. 

In  the  industries  the  powerful  oxidation  of  albuminous  sub- 
stances by  electric  ozonization  is  made  use  of  in  the  purification 
of  drinking  water.  Ozonizing  plants  are  now  in  practical  use  in 
several  large  European  cities  and  in  the  United  States.  It  is 
claimed  that  15  to  135  grains  (1  to  9  Gm.)  of  ozone  are  sufficient 
for  the  sterilization  of  24,025  cubic  inches  (1  cubic  meter)  of  pol- 
luted water. 

Of  the  many  dioxids,  hydrogen  dioxid,  the  dioxids  of  calcium, 
magnesium,  and  zinc,  and  the  perborate  of  sodium  and,  indirectly, 
oxone,  are  medicinally  employed.  Recently  some  organic  dioxids 
— succinic  dioxid  known  as  alphozon,  and  the  benzoyl-acetyl 
dioxid  known  as  acetozon — have  been  introduced  as  antiseptics  for 
internal  and  external  purposes.  Aside  from  its  action  as  an  anti- 
septic and  sterilizing  agent,  nascent  oxygen  is  employed  as  a 
bleacher  of  discolored  teeth,  and  as  an  oxidizing  or  reducing  agent 
in  certain  metallurgical  processes  in  the  dental  laboratory.  Gen- 
eral medicine  has  made  use  of  pure  oxygen  in  the  treatment  of 
pulmonary  diseases  and  as  a  restorative  agent  in  accidents  from 
general  anesthesia  or  in  poisoning  with  other  gases. 

Solution  of  Hydrogen  Dioxid;  Aqua  Hydrogenii  Dioxidi,  U.  S. 
P. ;  Liquor  Hydrogenii  Peroxidi,  B.  P. 

Synonyms. — Solution  of  hydrogen  peroxid,  pyrozon;  solution 
de  peroxide  d  'hydrogen,  eau  oxygenee,  F. ;  Wasserstoffsuper- 
oxydlosung,  Perhydrol,  Peraquin,  G. 

Source  and  Character. — Hydrogen  dioxid  was  discovered  by 
Thenardin  1818,  and  was  then  known  as  oxygenated  water.  It 
was  not  used  to  any  extent  until  Richardson,  in  1860,  introduced 
it  into  medicine.  It  is  often  found  in  small  quantities  in  the  at- 
mosphere after  heavy  storms,  or  by  any  other  process  in  which 
ozone  is  formed  in  the  presence  of  water.    Whenever  solutions  of 


ANTISEPTICS  137 

certain  dioxids — sodium  dioxid  or  barium  dioxid — are  treated 
with  diluted  acids,  it  is  readily  formed  according  to  the  following 
equation : 

Ba02+H2SO,=H202H-BaS04. 

For  manufacturing  purposes,  usually  barium  dioxid  is  decom- 
posed in  the  presence  of  sulphuric  or  phosphoric  acid;  the 
acids  form  an  insoluble  compound  with  the  barium.  For  dental 
purposes  an  alkaline  solution  of  hydrogen  dioxid  of  various 
strengths  may  be  extemporaneously  prepared  by  dissolving  sodium 
diborate  in  water.  Absolute  hydrogen  dioxid  (about  99  per  cent 
pure)  is  a  thick,  oily  colorless  liquid,  specific  gravity  1.45  which 
does  not  congeal  at  — 22°  F.  ( — 30°  C).  When  brought  in  con- 
tact with  certain  metals — gold,  silver,  platinum,  etc. — or  when  ex- 
posed to  sunlight  or  heat,  it  readily  decomposes,  often  with  ex- 
plosive violence.  The  official  preparation  is  a  slightly  acidulous 
aqueous  solution  of  hydrogen  dioxid,  containing,  when  freshly  pre- 
pared, about  3  per  cent  by  weight  of  the  pure  HgOg,  which  cor- 
responds to  about  10  per  cent  by  volume  of  available  oxygen.  It 
has  a  specific  gravity  of  1.006  to  1.007.  Its  solutions  are  prefer- 
ably stored  in  amber-colored  bottles,  away  from  light  and  sudden 
changes  of  temperature.  It  will  gradually  diminish  in  strength, 
and  age,  heat,  and  protracted  agitation  decompose  it  prematurely 
in  water  and  oxygen.  To  preserve  hydrogen  dioxid  solution,  tan- 
nic acid  and  acetanilid  in  small  quantities  have  been  suggested. 
Of  the  former,  about  1 :6,000  and  of  the  latter  about  1 :2,000  are 
necessary.  Almost  all  of  the  present  commercial  hydrogen  dioxid 
solutions  contain  small  quantities  of  acetanilid  as  a  preservative. 
The  ordinary  3  per  cent  solution  may  be  concentrated  by  carefully 
heating  it  to  a  temperature  not  over  140°  F.  (60°  C.)  on  a  water 
bath.  It  loses  chiefly  water,  but,  when  rapidly  heated,  it  is  apt 
to  explode.  It  is  incompatihle  with  alkalies,  albumin,  ammonia, 
arsenous  salts,  phenol,  chlorids,  ferric  salts,  iodids,  lime  water, 
mercurous  salts,  nitrates,  permanganates,  sulphates,  tartrates,  and 
with  most  tinctures. 

Aside  from  the  ordinary  3  per  cent  solution  of  hydrogen  dioxid, 
higher  concentrated  solutions  are  found  on  the  market.  A  25 
per  cent  solution  of  hydrogen  dioxid  in  ether  is  known  as  caustic 
pyrozon,  and  a  30  per  cent  solution  in  water  is  known  as  per- 
hydrol,  or  as  peraquin.     Caustic  pyrozon  is  put  up  in  glass  tubes 


138 


PHARMACO-THERAPEUTICS 


containing  a  few  cubic  centimeters,  while  perhydrol  is  marketed 
in  paraffin-lined  bottles  of  various  sizes.  In  opening  a  pyrozon 
tube  great  care  should  be  exercised  to  prevent  ex- 
plosion by  placing  the  tube  in  cold  water  and  wrap- 
ping it  in  a  wet  towel  before  the  end  is  broken  off. 
Its  contents  must  be  transferred  at  once  to  a  glass- 
stoppered  bottle,  provided  with  a  ground  cap,  to 
prevent  evaporation  of  the  ether.  Perhydrol  solu- 
tion is  to  be  greatly  preferred  whenever  a  highly 
concentrated  solution  of  hydrogen  dioxid  is  desired. 
It  is  a  chemically  pure  solution  of  H,20o  in  distilled 
water,  furnishing  about  30  per  cent  by  weight  or 
100  per  cent  by  volume  of  available  oxygen.  It  is 
absolutely  free  from  acid,  and  may  be  diluted  with 
water  or  alcohol  to  any  desired  strength.  Solutions 
should  preferably  be  made  fresh  when  needed.  If 
carefully  preserved  in  the  original  container  and 
stored  in  a  cool  place,  perhydrol  will  retain  its  oxy- 
gen for  some  time.  Very  recently,  hydrogen  dioxid 
in  diy  form,  known  as  perhydrit,  has  been  placed 
on  the  market.  Perhydrit  is  a  compound  of  hy- 
drogen dioxid  and  urea,  containing  about  30-35  per 
cent  of  available  hydrogen  dioxid.  It  is  a  very 
unstable  compound. 

A  simple  test  for  hydrogen  dioxid  is  made  as  follows: 
Mix  10  cubic  centimeters  of  distilled  water  with  10  drops 
of  diluted  sulphuric  acid,  1  drop  of  potassium  chromate 
test  solution  (1  part  potassium  chromate  dissolved  in  suffi- 
cient water  to  make  100  cubic  centimeters),  and  2  cubic 
centimeters  of  ether.  On  the  addition  of  the  solution  con- 
taining hydrogen  dioxid,  a  blue  color  will  appear  at  the 
line  of  contact  which  will,  after  shaking,  separate  with  the 
ethereal  layer. 

Average  Dose. — 1  fluidram  (4  C.c). 
Minim  syringe  THERAPEUTICS. — The  ideal  external  antiseptic  for 

H20!  Toiiuions^      ^^^  body — the  skin,  external  mucous  membranes, 
and  wound  surfaces — is  a  substance  which  destroys 
the  bacteria  and  their  products,  but  which  will  not  harm  the  tis- 
sues of  the  host.     Hydrogen   dioxid  approaches  this  ideal  more 


Fig.  27. 


ANTISEPTICS 


139 


closely  than  any  other  known  antiseptic.  When  brought  in  con- 
tact with  bacteria  and  their  products,  it  acts  as  a  powerful  anti- 
septic and  deodorant;  it  is  not  absorbed  by  the  tissues,  but  by  its 
reaction  with  the  living  cell  it  is  split  up  into  oxygen  and  water.^ 
This  decomposition  of  hydrogen  dioxid  into  molecular  oxygen  and 
water  depends  primarily  upon  the  presence  of  the  ferment  cata- 
lase.  This  ferment  is  present  everywhere  in  living  animal  tissues, 
especially  in  the  blood  and  in  all  secretions  and  excretions,  includ- 
ing the  saliva.  More  or  less  all  fungi  and  bacteria  contain  ap- 
preciable quantities  of  catalase.  According  to  Heinz^  its  action 
on  staphjdococcus  pyogenes  aureus  and  bacillus  pyocyaneus  is 
recorded  as  follows : 


SOLUTION  OF  HYDROGEN  DIOXID 


staphylococcus  pyogenes  aureus 

Bacillus  pyocyaneus 

Concentration 

After 
24  hours 

After 
48  hours 

After 
72  hours 

After 
24  hours 

After              After 
48  hours         72  hours 

1  percent 

0.75  percent 

0.5    percent 

0.25  percent 

0.1    percent 

+ 

+ 

+ 

+ 
+ 

+ 
+ 

+ 

Much  confusion  seems  to  exist  in  the  minds  of  some  practition- 
ers relative  to  the  nature  of  acidity  of  hydrogen  dioxid  solutions. 
It  should  be  remembered  that  normally  the  official  solution  of  hy- 
drogen dioxid  is  "a  slightly  acid,  aqueous  solution,"  the  acidity 
corresponding  to  10  C.c.  of  a  tenth-normal  sulphuric  acid,  V.S. 
(U.  S.  P.)  to  100  C.c.  of  the  dioxid  solution.  Unfortunately,  many 
of  the  commercial  preparations  contain  much  higher  percentages 
of  acid,  as  much  as  26.6  C.c.  of  a  tenth-normal  sulphuric  acid  has 
been  found.  While  some  of  this  acid  content  may  be  of  an  or- 
ganic nature  as  a  I'csult  of  the  decomposition  of  the  preservative 
acetanilid  added  to  the  dioxid  solution,  nevertheless,  too  high  per- 
centages of  inorganic  acids  are  frequently  observed.  Distinct 
marks  of  decalcification  of  tooth  structure  in  the  mouths  of  per- 
sons who  use  such  acid  compounds  as  a  daily  mouth  Avash  have  been 
observed,  hence  the  importance  of  rendering  the  dioxid  solution 


>Fette:  Dental  Cosmos,  1915,  p.  615. 

'Heinz:   Handbuch  dcrMxperiniciitellen   Pathologic  und    I'harniakologie,   1904. 


140 


PHARMACO-THERAPEUTICS 


alkaline  by  the  addition  of  small  quantities  of  borax  at  the  time 
of  its  use.  An  absolute  neutral  preparation  may  be  obtained  by 
the  proper  dilution  of  perhydrol  with  distilled  water. 

When  hydrogen  dioxid  is  brought  in  contact  with  blood,  pus, 
serum,  wound  exudates,  etc.,  it  produces  a  heavy  froth  as  a  result 
of  the  catalytic  action  of  the  ferment  catalase,  incidentally  destroy- 
ing the  bacteria  chemically  and  cleansing  the  wound  surfaces 
mechanically.  It  acts  as  a  strong  deodorant  by  oxidizing  the  odor- 
ous gases  arising  from  putrefactive  processes.  It  should  not  be  in- 
jected into  pus  cavities  unless  free  drainage  is  established,  as 
otherwise  the  free  liberation  of  oxygen  will  force  the  infection  into 
deeper  structures.  The  same  principle  holds  good  in  treating  dis- 
turbances of  the  antrum  of  Highmore.  To  remove  any  obstruc- 
tions, it  should  always  be  preceded  in  such  cases  by  copious  in- 


Fig.  28. 
Pyrozon  Probe  Cup. 


jections  of  physiologic  salt  solution  heated  to  body  temperature. 
On  fresh  granulating  surfaces  it  should  not  be  emploj^ed,  as  it 
tends  to  break  down  this  new  delicate  tissue  growth.  In  the 
various  forms  of  stomatitis,  and  as  a  prophylactic  in  mercurial  ad- 
ministration in  syphilis,  it  deserves  to  be  highly  recommended,  and 
especially  when  combined  with  a  metallic  astringent  and  rendered 
slightly  alkaline  as,  for  instance,  by  the  addition  of  small  quantities 
of  borax.  H2O2  solutions  possess  distinct  styptic  properties;  they 
should  not  be  used  for  such  purposes  in  root  canals,  as  their  ac- 
tion on  the  hemoglobin  of  the  blood  may  cause  a  discoloration  of 
the  tooth  structure.  Strong  solutions  of  HoOz  (pyrozon,  perhy- 
drol) are  powerful  caustics,  and  they  are  used  as  such  for  the  de- 
struction of  gum  tissue,  in  fistulous  tracts,  in  pockets  of  pyorrhea! 


ANTISEPTICS  141 

teeth,  and  as  styptics  in  severe  hemorrhage.  Andresen^  advocates 
perhydrol  as  the  sovereign  remedy  in  the  treatment  of  hypersensi- 
tive dentin,  especially  in  cervicat  cavities.  It  will  not  blacken  the 
cavity  like  silver  nitrate,  which  is  usually  employed  for  such  pur- 
poses, but  instead  whitens  the  tooth  structure.  The  caustic  solu- 
tion requires  careful  handling,  and  the  soft  tissues  have  to  be  well 
protected  by  suitable  napkins,  a  coating  of  vaselin,  etc.  Burns 
from  caustic  HgOg  solutions  are  relieved  by  immediate  washings 
with  water  and  covering  the  burned  surfaces  with  a  mild  ointment. 
In  using  these  powerful  solutions  it  is  good  practice  to  pour  the 
necessary  quantity  into  a  watch  crystal  or  into  a  "pyrozon  probe 
!iup,"  and  then  apply  it.\vith  a  suitable  applicator,  a  platinum 
minim  syringe,  wooden  probe,  etc.  Great  care  should  be  exercised 
to  prevent  the  caustic  solution  from  coming  in  contact  with  wool- 
en fabrics,  as  it  will  char  them,  or  even  set  them  on  fire. 

Antiseptic  Solutions. 

R     Hydrargyr.  chlorid.  gr.  j   (0.06  Gm.) 

Aquae  hydrogen,  dioxid.  fl5  ij    (60  C.c.) 

M. 

Sig.:     Inject  with  a  platinum  pointed  syringe  into  pus 
pockets  in  pyorrhea. 

IJ     Resorsinol  3  j   (4  Gm.) 

Zinc,  chlorid.  gr.  x   (0.65  Gm.) 

Menthol.  gr.  xx   (1.3  Gm.) 

Thymol.  gr.  xv   (1.0  Gm.) 

Glycerin.  flS  j  (30  C.c.) 

Alcohol.  flS  ij  (60  C.c.) 

AqusB  hydrogen,  dioxid.  ad  flS  viij  (240  C.c.) 

M. 

Sig.:     Teaspoonful  in  a  tumblerful  of  warm  water  as  a 

gargle  in  syphilis  of  the  mouth. 

Oxygen  ;  Oxygenium,  U.  S.  P. ;  0 ;  Oxygene,  F.  ;  Sauerstoff,  G. 

Source  and  Character. — Oxygen  may  be  prepared  from  heat- 
ing at  a  low  temperature  a  mixture  of  5  parts  of  potassium  chlo- 
rate and  1  part  of  manganese  dioxid.  It  must  be  purified  before 
storing  by  passing  it  through  wash  bottles  containing  alkali,  and 
is  dried  by  passing  it  through  sulphuric  acid.    It  may  be  liquefied 


*Andresen:  Deutsche  Monatsschrift  fur  Zahnheilkunde,  190S,  p.  25. 


142 


PHARMACO-THERAPEUTICS 


b.y  pressure,  forming  a  bluish  liquid,  which  can  be  readily  stored 
in  steel  cylinders.  In  commerce  these  cj'linders  contain  40,  75,  and 
100  gallons  of  the  compressed  gas«i'espectively,  and  are  painted  red 
to  differentiate  them  from  the  nitrous  oxid  cylinders,  which  are 
painted  black. 

Pure  oxygen  is  readily  obtained  by  decomposing  oxone,  a  solid, 
fused  sodium  dioxid.  Oxone  is  neither  combustible  nor  explosive ; 
it  may  be  stored  in  air-tight  tin  cans  for  any  length  of  time,  or 
may  be  transported  without  danger,  and  is  always  ready  for  use. 
When  oxone  is  brought  in  contact  with  w^ater  it  instantaneously 
produces  oxygen.    Approximately  one  pound  (453  Gm.)  furnishes 


Fig.  29. 

Oxygen   inhalation   apparatus.      A  cylinder  of  liquid   oxygen   connected   with   a   wash   bottle 
half   filled   with  water,   and   rubber   tubing,   ready   for   use. 

two  cubic  feet  (60  liters)  of  pure  oxygen,  which  corresponds  to 
about  320  times  its  own  weight.  A  very  simple  apparatus,  the 
oxone  generator,  made  by  the  Foregger  Company,  Inc.,  of  New 
York,  is  readily  available  for  such  purposes.  One  charge  of  the 
apparatus  furnishes  about  fourteen  to  fifteen  gallons  of  pure 
oxygen  within  a  few  moments'  time.  So  far  as  known,  it  is  the 
simplest  method  of  obtaining  pure  oxygen  for  medicinal  purposes 
and  for  the  laboratory.  The  value  of  an  oxone  generator  is  readily 
appreciated  by  those  who  utilize  pure  oxygen  in  their  practice. 
Oxygen  is  a  colorless,  inodorous  gas;  1  liter  weighs  1.43  grams 


ANTISEPTICS  143 

at  32°  F.  (0°  C),  and  100  volumes  of  water  at  32°  F.  (0°  C.)  dis- 
solve 4.1  volume  of  oxygen.  It  combines  readily  with  most  ele- 
ments, forming  oxids.  This  process  is  known  as  oxidation,  and, 
when  attended  by  great  heat  and  light,  as  combustion. 

Therapeutics. — Oxygen  is  necessary  to  carry  on  life.  In  the 
form  of  air  (^,  of  the  atmosphere  is  oxygen,  the  remainder  being 
nitrogen,  with  small  proportions  of  carbon  dioxid,  etc.),  it  fur- 
nishes the  means  for  oxidation  of  some  of  the  waste  products  of 
the  body.  In  plant  life  two  processes,  oxydase  and  catalase,  re- 
spectively bind  or  furnish  free  oxygen.  The  latter  is  essential 
for  the  maintenance  of  the  vegetable  cell.    In  medicine  pure  oxy- 


iMg.   3C. 
Portable  oxone  generator  (Autogenor).     Closed. 

gen  gas  is  used  by  inhalation  in  pulmonary  diseases  and  as  a  re- 
storative agent  in  those  conditions  where  the  tissues  have  been  im- 
perfectly supplied  with  this  gas — as  in  coal  gas  poisoning,  anes- 
thesia, etc.  It  is  also  used,  in  combination  with  nitrous  oxid,  for 
anesthetic  purposes  to  overcome  cyanosis  and  to  furnish  enough 
oxygen  with  the  anesthetic  vapor  to  maintain  life. 

Calcium  Dioxid;  Calcii  Dioxidi;  CaOg;  Calcium  Peroxid; 

BORITE. 

It  is  a  light-yellow  powder,  odorless  and  tasteless,  and  contain- 
ing about  13  per  cent  available  oxygen.    It  is  almost  insoluble  in 


144 


PHARMACO-THERAPEUTICS 


water,  but  decomposes  in  the  presence  of  moist  organic  matter. 
Weak  acids  readily  decompose  it  into  active  oxygen  and,  usually, 
into  insoluble  calcium  salts.  Calcium  dioxid  has  been  advocated 
as  a  component  of  tooth  poAvders  for  the  purpose  of  liberating  free 
oxygen  in  the  mouth.  It  is  not  as  well  suited  for  this  purpose  as 
some  of  the  other  oxygen  compounds.  (See  Preparations  for  the 
Mouth  and  Teeth.)  As  an  internal  remedy  it  is  much  lauded  in 
acid  dyspepsia  and  in  summer  diarrhea  of  children  in  3  to  10- 
grain  (0.2  to  0.6  Gm.)  doses.     Calcium  dioxid  is  also  largely  used 


Fig.  31. 
Portable  oxone  generator   (Autogenor).     Opened. 

in  the  industries  as  a  harmless  preservative  of  foods,  for  aging 
beverages,  as  a  preventive  of  seed  diseases,  etc. 

Magnesium  Dioxid;  Magnesii  Dioxidi;  MgOg;  Magnesium  Per- 
oxiD;  Magnesium  Perhydrol;  Biogen. 

It  is  a  compound  of  magnesium  dihydroxid  and  magnesium  hy- 
droxid,  containing  from  20  to  30  per  cent  of  pure  magnesium  di- 
oxid and  averaging  about  7  to  8  per  cent  available  oxygen.  It  is 
a  tasteless,  white,  amorphous  powder,  almost  insoluble  in  water, 
but  readily  soluble  in  the  presence  of  acid  media.  On  account  of 
its  very  mild  alkalinity  it  is  much  lauded  as  a  component  of  tooth 
powders  (see  Preparations  for  the  Mouth  and  Teeth),  and  is 
freely  administered  internally  in  4  to  8-grain  (0.25  to  0.5  Gm.) 
doses  in  rheumatism,  diarrhea,  intestinal  diseases,  etc.  As  a  means 
of  furnishing  free  oxygen  to  cell  activity  and  thereby  increasing 


ANTISEPTICS  145 

metabolism,  it  is  recommended,  although  the  claims  for  such  ac- 
tion have  as  yet  not  been  substantiated.  Under  the  name  of 
biogen  it  has  been  widely  advertised  for  such  purposes.  Mag- 
nesium dioxid  can  be  safely  employed  as  a  harmless  disinfectant 
for  the  sterilization  of  drinking  water. 

Strontium  Dioxid;   Strontium   Dioxidi;   SrOg;   Strontium 

Peroxid. 

It  contains  about  80  per  cent  of  pure  strontium  dioxid  and  fur- 
nishes about  12  per  cent  available  oxygen.  It  is  a  voluminous 
white  powder,  almost  insoluble  in  water,  but  parts  with  its  oxy- 
gen in  the  presence  of  acids.  In  its  general  behavior  it  resembles 
closely  calcium  dioxid,  and  is  used  more  or  less  for  the  same  pur- 
poses. 

Sodium  Dioxid;  Sodii  Dioxidi;  NagOg;  Sodium  Peroxid. 

Sodium  dioxid  is  a  yellowish  powder,  which  is  readily  soluble  in 
water,  developing  great  heat  with  the  formation  of  caustic  soda 
and  the  evolution  of  hydrogen  dioxid.  It  is  a  very  hygroscopic 
salt,  and  must  be  kept  in  tightly  closed  tin  cans  or  glass  bottles. 
To  ascertain  its  efficiency,  the  following  simple  test  may  be  em- 
ployed: In  a  clean,  dry  test  tube  place  about  15  grains  (1  Gm.) 
of  the  powder  and  add  to  it  15  to  30  minims  (1  to  2  C.c.)  of  water. 
If  the  specimen  is  of  a  good  quality,  enough  oxygen  should  be  gen- 
erated to  kindle  a  glowing  splinter  held  at  the  mouth  of  the  tube. 
Sodium  dioxid  is  an  exceedingly  active  oxidizer.  It  was  intro- 
duced into  dentistry  in  1893  by  Kirk  for  the  purpose  of  bleaching 
teeth  (see  Bleaching  Agents)  and  for  the  treatment  of  putrescent 
root  canals.  (See  Decomposition  of  the  Tooth  Pulp,  etc.)  For 
such  purpose  it  is  used  as  a  dry  powder  or  in  the  form  of  a  concen- 
trated aqueous  solution.  The  latter  is  best  prepared  extempo- 
raneously as  follows:  Place  a  thin  beaker,  holding  a  few  drams  of 
distilled  water,  in  a  basin  filled  with  cold  water  or  pounded  ice,  and 
sift  slowly  small  quantities  of  sodium  dioxid  into  the  water  until 
a  saturated  solution  is  obtained,  which  is  manifested  by  a  semi- 
opaque  appearance  of  the  latter.  The  dioxid  solution  will  clear 
up  in  a  few  moments,  presenting  a  straw-colored  appearance,  when 
it  is  ready  for  use.  When  sodium  dioxid  is  fused,  a  solid  mass  is 
obtained,  which  is  marketed  as  "oxone. "  (See  Oxygen.) 


146  PHARMACO-THERAPEUTICS 

Zinc  Dioxid;  Zinci  Dioxidi;  ZiiO,;  Zinc  Peroxid;  Zinc  Per- 

HYDROL;  DeRMOGEN. 

It  is  a  superoxidized  zinc  oxid,  containing  about  45  per  cent  of 
pure  zinc  dioxid,  and  averaging  about  8  per  cent  available  oxygen. 
It  is  a  yellowish-white  powder,  insoluble  in  water,  but  readily 
soluble  in  an  acid  medium.  In  the  presence  of  moisture  from  a 
wound,  moist  skin  surfaces,  etc.,  it  will  slowly  and  continuously 
liberate  active  oxygen ;  the  remaining  zinc  oxid  is  a  nonirritating 
astringent.  Hence  its  greatest  field  of  therapeutic  application  lies 
in  the  domain  of  the  dermatologist.  It  is  widely  used  in  skin  dis- 
eases as  a  dusting  powder  or  in  the  form  of  ointments,  and  it  is 
much  lauded  for  the  treatment  of  burns.  When  applied  in  the 
form  of  an  ointment  it  should  never  be  mixed  with  an  animal  fat, 
as  it  will  decompose  the  latter,  forming  rancid  (fatty  acid)  com- 
pounds with  the  ointment  base,  which  would,  of  course,  irritate  the 
skin  or  wound  surfaces.  Liquid  or  solid  petrolatum  are  the  only 
permissible  bases  for  such  purposes. 

H     Zinc,  dioxid.  3  j   (4.0  Gm.) 

Petrolat.  alb.  5  j   (30.0  Gm.) 

M.  f.  ungt. 

Sig.:     Ointment  for  burns. 

I{     Zinc,  dioxid.  5  ij   (8.0  Gm.) 

Acid,  boric.  5  ss   (15.0  Gm.) 

Talc,  purific.  ad  5  ij   (GO.O  Gm.) 

M.  f.  plv. 
Sig.:     Dusting  powder  for  wounds. 

Sodium  Diborate;  Sodii  Perboras,  U.  S.  P. ;  NaB03+4H20 ;  Sodium 

Perborate. 
It  should  furnish  not  less  than  9  per  cent  of  available  oxygen.  It 
is  a  white  crystalline  powder,  readily  soluble  in  about  40  parts  of 
water  forming  a  colorless  alkaline  solution  of  hj^drogen  dioxid.  With 
a  rise  of  temperature  and  the  addition  of  small  quantities  of  acids, 
the  solubility  of  sodium  diborate  is  increased  and  solutions  of 
various  strengths  may  be  readily  obtained.  Extemporaneously, 
solutions  of  this  mixture  may  be  prepared  as  follows: 

2  Per  Cent  (by  Volume)  Solution. 

IJ     Sodium  diborate  5  j    (30  Gm.) 

Boiling  distilled  water, 

enough  to  make  fl5  xxxij   (1000  C.c.) 

Filter  if  necessary. 


ANTISiii^TlCS  14? 

5  Per  Cent  (by  Volume)  Solution. 

H     Sodium  diborate  5  ii   (C5  Gm.) 

Tartaric  or  citric  acid, 

powdered  3  v  (20  Gin.) 

Boiling  distilled  water, 

enough  to  make  fl5  xxxij   (1000  C.c.) 

Filter  if  necessary. 

10  TO  12  Per  Cent  (by  Volume)  Solution. 

n     Sodium  diborate  5  vij   (210  Gm.) 

Tartaric  or  citric  acid, 

powdered  5  iijss   (100  Gm.) 

Boiling  distilled  water, 

enough  to  make  flB  xxxij    (1000  C.c.) 

Filter  if  necessary. 

On  account  of  their  mild  alkalinity,  these  freshly  made  solu- 
tions of  hj'drogen  dioxid  are  especially  useful  in  those  diseases  of 
the  mucous  membrane  where  the  acidity  of  the  ordinary  hydro- 
gen dioxid  is  an  objection.  As  an  addition  to  tooth  powders,  dust- 
ing powders,  dry  dressings,  etc.,  sodium  diborate  is  a  valuable 
means  of  furnishing  nascent  oxygen  in  the  presence  of  moisture. 

Pergenol. — A  mixture  of  sugar,  citric  acid  and  sodium  diborate 
and  compressed  into  tablets  and  recommended  for  the  extempora- 
neous preparation  of  dioxid  solutions. 

Recently  some  organic  dioxids  have  been  introduced.  These 
substances  part  with  their  oxygen  less  readily  than  the  inorganic 
oxygen  compound.  Commercially,  two  of  these  compounds  are 
available  at  present — alphozon,  a  succinyl  dioxid,  and  acetozon, 
a  benzoyl-acetyl  dioxid.  Both  chemicals  are  advocated  as  inter- 
nal antiseptics  and  as  bleaching  agents.  Their  chemistry  and 
physiologic  action  is  at  present  not  fully  worked  out. 

Oxygenated  Talcum  Powder. 

Purified   talc  5  iij    (94  Gm.) 

Sodium    diborate  3  j  14   (5  Gm.) 

Essence  of  violet  gtt.  xvi   (1  C.c.) 


148  phakmaco-therapeutics 

Oxygenated  Hand  Cleanser   (Finger  Bleach). 

Castile  soap,  powdered  S  j   (30  Gm.) 

Pumice  stone,  powdered  3  ss  (2  Gm.) 

China  clay  5  jss  (45  Gm.) 

Sodium  diborate  3  v  (20  Gm.) 

Oil  of  sweet  orange  gtt.  viij    (i/^  C.c.) 

Oil  of  bergamot  gtt.  viij    (1/4  C.c.) 

Oil  of  bitter  almonds  gtt.  xxxij    (2  C.c.) 

Potassium  Permanganate;  Potassii  Permanganas,  U.  S.  P.,  B. 
P.;  KMnO^;  Permanganate  de  Potasse,  F. ;  Uebermangan- 
SAURES  Kali,  G. 

Source  and  Character. — It  appears  in  dark-purple  or  deep 
violet-red  slender  crystals,  which  have  a  bluish,  metallic  luster.  It 
is  odorless  and  has  an  astringent  taste.  It  is  readily  soluble  in  15 
parts  of  water  at  ordinary  temperature,  very  soluble  in  boiling 
water,  while  when  brought  in  contact  with  alcohol  it  is  decom- 
posed. Its  aqueous  solutions,  which  react  neutral  to  litmus  paper, 
have  a  deep-violet  color  when  concentrated  and  a  rich  rose  color 
when  much  diluted.  Readily  oxidizable  substances — as  glycerin, 
citric  acid,  acetic  acid,  tartaric  acid,  sugar,  gum,  tannin,  etc. — are 
quickly  oxidized  when  brought  in  contact  with  potassium  per- 
manganate solutions.  When  mixed  with  glycerin,  syrup,  and  other 
organic  liquids,  or  when  triturated  in  a  mortar  with  sulphur  or 
other  inflammable  bodies,  the  mixture  readily  explodes. 

Solution  of  Potassnnn  Permanganate;  Liquor  Potassii  Per- 
manganas, B.  P.    A  1  per  cent  solution  of  the  salt  in  water. 

A  paste  made  of  potassium  permanganate,  charcoal,  and  petro- 
latum is  known  as  styptogan,  and  is  used  as  an  external  styptic. 
Condy's  fluid,  a  commercial  preparation,  which  is  much  used  in 
Great  Britain,  is  a  concentrated  solution  of  potassium  perman- 
ganate, and  is  principally  employed  for  disinfecting  purposes. 

Therapeutics. — Potassium  permanganate  has  been  much 
lauded  as  an  oral  antiseptic  and  deodorant.  Only  concentrated 
solutions  are  of  service  for  such  purposes,  but,  on  account  of  the 
persistent  discoloration  of  the  teeth  resultant  from  the  precipita- 
tion of  manganese  oxid  and  of  the  deleterious  action  on  tooth  sub- 
stances, it  should  not  be  used  in  the  mouth.  In  weak  solutions 
(1:2,000)  it  is  of  some  service  in  washing  out  abscess  cavities, 
the  antrum  of  Highmore,  etc.     Recently    concentrated    solutions 


ANTISEPTICS 


149 


of  potassium  permanganate  have  been  recommended  for  the  local 
treatment  of  snake  bites.  When  it  comes  in  direct  contact  with 
the  poison  it  has  undoubtedly  some  value,  and  it  may  be  used  for 
such  purposes  as  a  wash. 

Potassium  Chlorate  ;  Potassii  Chloras,  U.  S.  P.,  B.  P. ; 
Kalium  Chloricum,  p.  G.  ;  KCIO3. 

Synonyms. — Chlorate  of  potash,  kali  oxymuriaticum ;  chlorate 
de  potasse,  F. ;  Chlorsaures  Kali,  G. 

Source  and  Character. — It  appears  in  colorless,  shining  plates 
or  crystals;  it  is  odorless,  and  has  a  soothing  saline  taste  and  a 
neutral  reaction.  When  heated  to  about  634°  F.  (334°  C.)  it 
melts,  and  at  a  slightly  higher  temperature  gives  up  free  oxygen. 
Potassium  chlorate  is  soluble  in  about  16  parts  of  water  at  ordi- 
nary temperature,  very  soluble  in  hot  water,  and  soluble  in  about 
130  parts  of  alcohol.  When  brought  in  contact  with  organic  mat- 
ter— cork,  tannic  acid  and  its  many  modifications,  sugar,  etc. — or 
with  easily  oxidizable  substances — sulphur,  phosphorus,  antimony 
sulphid — or  if  the  mixture  is  subjected  to  heat,  trituration,  or 
concussion,  violent  explosions  are  liable  to  occur.  Special  care 
should  be  exercised  in  prescribing  the  salt  as  a  component  of  tooth 
powders. 

Therapeutics. — Potassium  chlorate  has  a  very  limited  range  of 
usefulness.  At  one  time  it  was  believed  that  this  salt  possessed 
specific  properties  which  made  it  invaluable  for  the  treatment  of 
infectious  disturbances  of  the  oral  cavity.  This  belief  is  still  en- 
tertained by  many  practitioners.  Kobert,  Cushny,  Heinz,  and 
others  have  called  attention  to  the  easy  manner  in  which  this  salt 
is  readily  absorbed  by  the  tissues  when  used  as  a  gargle.  After 
it  has  entered  the  blood  it  produces  severe  changes,  resulting  in 
the  destruction  of  the  red  blood  corpuscles,  with  the  production 
of  hemoglobinuria,  a  condition  which  is  known  as  "potassium 
chlorate  poisoning."  Cases  are  on  record  where  the  simple  gar- 
gling with  potassium  chlorate  solution  has  resulted  in  death. 
About  90  per  cent  of  the  absorbed  potassium  chlorate  is  excreted 
by  the  urine,  and  the  balance  leaves  the  body  through  the  salivary 
and  other  glands.  Its  antiseptic  action  is  about  equal  to  sodium 
chlorid.  Recently  potassium  chlorate  has  been  again  introduced 
in  the  form  of  a  tooth  paste,  containing  50  per  cent  of  the  salt, 
as  a  panacea  for  the  treatment  of  mercurial  stomatitis,  gingivitis, 


150  PHARMACO-THERAPEUTICS 

and  other  disturbances  of  the  oral  cavity.  Potassium  chlorate  in 
the  form  of  a  paste,  powder,  or  as  a  gargle  in  diseases  of  the 
mouth,  or  as  a  toilet  requisite  for  daily  use,  should  be  emphatic- 
ally prohibited. 

Antiseptics  of  the  Aromatic  Series. 

According  to  the  earliest  historical  records,  the  balsams,  the 
spices,  and  wood  tar  and  many  of  its  derivatives  have  been  util- 
ized to  check  the  effects  of  decay  and  to  heal  wounds.  The  Assy- 
rians, Persians,  and  especially  the  Egyptians  employed  these  sub- 
stances very  largely  for  the  preservation  of  their  dead  by  embalm- 
ing. Herodotus  has  left  us  a  fairly  good  description  of  the  meth- 
ods employed  by  the  Egj^ptians.  After  a  person  had  died  the 
brain  and  abdominal  viscera  were  removed,  the  body  was  thor- 
oughly washed  and  cleansed,  and  saturated  with  aromatic  sub- 
stances and  bitumen.  It  was  then  subjected  for  seventj-  days  to  a 
strong  brine  solution,  dried,  and  wrapped  or  swathed  in  cloth  that 
was  liberally  saturated  with  aromatics.  The  prepared  body  was 
then  "laid  to  rest  in  the  tomb  to  await  the  summons  to  the  Elysian 
fields  of  Aahlu. "  With  the  introduction  of  phenol  into  surgery 
by  Lister  in  1868  the  aromatics  have  become  important  factors 
in  the  treatment  of  wounds.  A  very  large  number  of  chemicals 
belonging  to  the  aromatic  series  have  been  discovered  within  the 
last  thirty  years;  some  have  become  important  constituents  of 
materia  medica,  while  othei's,  after  a  verj-  brief  sojourn,  have  been 
discarded. 

Of  the  hydroxyl  compounds,  phenol,  C^HsOH,  is  the  most  im- 
portant member;  it  is  the  oldest  important  representative  and  is 
still  largely  used.  By  substituting  chlorin  for  hydrogen  in  the 
benzol  ring,  monoehlorophcnol,  CV.H^CIOH,  is  formed.  By  oxida- 
tion three  dioxjbenzols  are  obtained,  of  which  rcsorcinol. 
C,;H^(0H)2  stands  out  very  prominently.  The  latter  is  reported 
as  being  an  oral  antiseptic  of  some  repute.  Closely  related  to  the 
phenols  are  the  cresols;  the  latter  are  largely  used  at  present  in 
the  form  of  cresol,  C.H-.OH— that  is,  a  mixture  of  the  three 
isomeric  cresols,  or  in  the  form  of  any  of  the  many  modifications 
of  which  the  compound  solution  of  cresol  is  the  best  representative. 
Thymol,  C^oHj^O,  and  its  isomer  carvacrol,  are  prepared  from  oil 
of  thyme.  The  former  is  much  lauded  in  dentistry.  Of  the 
naphtols  the  betanaphtol,    C,nH-OH    (hydronaphtol)    has    found 


ANTISEPTICS 


151 


manj'  admirers.  Creosote,  a  mixture  of  phenol  and  phenol  deriva- 
tives, prepared  from  beechwood  tar,  has  been  used  widely  in  den- 
tistry, even  long  before  the  inauguration  of  the  antiseptic  era.  Its 
chief  constituents,  guaiacol,  C^HgOo,  is  much  praised,  either  alone 
or  in  any  of  its  many  modifications,  as  an  internal  antiseptic  in 
tuberculosis.  Through  the  introduction  of  the  carboxyl  group, 
COOH,  into  the  aromatic  series  many  important  compounds  are 
formed  which  are  much  less  poisonous  than  the  original  phenol. 
Some  of  the  important  representatives  of  this  group  are  salicylic 
acid  and  benzoic  acid,  and  their  many  derivatives.  A  very  large 
group  of  aromatic  antiseptics  is  represented  by  the  essential  oils 
and  their  derivatives,  and  their  imx)ortance  in  dentistry  necessi- 
tates detailed  description  in  a  special  chapter. 

The  antiseptics  of  the  aromatic  series  play  a  very  important  role 
in  the  practice  of  conservative  dentistry  and  oral  hygiene,  and  are 
principally  applied  locally.  When  the  aromatic  poisons  are 
brought  in  contact  with  living  protoplasm,  they  kill  the  cell  with- 
out visible  changes,  and  consequently  they  are  referred  to  as 
protoplasm  poisons.  It  is  claimed,  and  clinical  experience  seems 
to  verify  this  fact,  that  a  solution  of  several  antiseptics  of  this  and 
other  groups  are  more  strongly  antiseptic  than  those  containing 
only  an  equal  percentage  of  the  individual  chemical.  The  strong- 
est antiseptic  action  is  obtained  from  those  substances  which  are 
readily  soluble  in  a  fluid  which  is  also  soluble  in  the  protoplasm 
of  the  cell.  Quite  a  few  of  the  antiseptics  of  the  aromatic  series 
act  as  caustics  by  precipitating  albumin  when  applied  in  concen- 
trated aqueous  solution.  It  should  be  borne  in  mind,  however, 
that  the  newly  formed  precipitate  is  of  a  loose,  floeculent  nature, 
which  does  not  chock  the  further  penetration  of  the  antiseptic. 

Phenol  ;  Phenol,  U.  S.  P. ;  Acidum  Carbolicum,  B.  P. ; 
C,jHi.,OH;  Carbolic  Acid. 

Synonyms. — Phenic  or  phenylic  acid,  phenyl  hydroxid,  hy- 
drozybenzol ;  acide  phenique,  F. ;  Carbolsaure,  G. 

Source  and  Character. — Phenol  was  discovered  in  1834  in 
coal  tar  by  Runge.  It  is  obtained  from  coal  tar  by  fractional  dis- 
tillation or  made  synthetically.  It  appears  in  colorless,  needle- 
shaped  crystals  or  white  masses,  which  melts  at  about  104°  F. 
(40°  C),  having  a  peculiar  odor  and  a  sweetish,  burning  taste. 
It  is  deliquescent  in  moist  air.    By  age  the  liquid  phenol  usually 


152 


PHARMACO-THERAPEUTICS 


acquires  a  slightly  pinkish  tint ;  this  is  not,  however,  an  indication 
of  any  impurity,  as  it  develops  most  rapidly  in  the  pure  acid  and 
does  not  in  any  way  affect  its  medicinal  action.  Phenol  is  soluble 
in  about  20  parts  of  pure  water  at  ordinary  temperature;  it  is 
very  soluble  in  alcohol,  ether,  chloroform,  and  glycerin,  and  in 
fixed  and  volatile  oils.  It  reacts  faintly  acid  to  blue  litmus  paper. 
Phenol  is  frequently  confounded  with  creosote,  with  which  it  is 
identical  in  many  points. 
Chief  Points  of  Difference  Between  Phenol  and  Creosote. — 


PHENOL. 

Soluble  in  about  20  parts  of  water. 
Freely  soluble  in  glycerin. 
Crystallizable. 

Ferric  chlorid  test  solution  produces  a 
permanently  violet-blue  color. 


CEEOSOTE. 

Soluble  in  about  140  parts  of  water. 
Insoluble  in  glycerin. 
Not  crystallizable. 

Ferric  chlorid  test  solution  produces  a 
very  transient  violet-blue  color. 


It  is  stated  in  some  text  books  that  phenol  will  coagulate  al- 
bumin, while  creosote  will  not.  This  certainly  is  a  mistake,  as 
both  behave  in  exactly  the  same  manner  toward  albumin. 

Average  Dose. — 1  grain  (0.065  Gm.). 

Medical  Properties. — Antiseptic,  antipyretic,  caustic,  anes- 
thetic. 

PrEPxYRATIONS. — 

PheTwl  Liquef actum;  Liquid  PJienol,  U.  S.  P. ;  Acidum  Car- 
bolicum  Liquef  actum,  B.  P. ;  Liquid  Carbolic  Acid.  It  is  liquefied 
phenol,  containing  about  13.6  per  cent  by  weight  of  water.  Aver- 
age dose,  1  minim  (0.05  C.c). 

Glyceritum  PJienolis;  Glyceriie  of  Plienol,  U.  S.  P. ;  Glycerinum 
Acidi  Carholici,  B.  P.  A  mixture  of  20  parts  of  liquid  phenol  and 
80  parts  of  glycerin. 

Unguentum  PJienolis;  Ointment  of  Phenol,  U.  S.  P. ;  Unguen- 
tum  Acidi  Carholici,  B.  P. ;  Ointment  of  Carbolic  Acid.  It  con- 
tains 5  per  cent  of  phenol. 

Zinci  PJienolsidpJionas ;  Zinc  PJienolsidpJionate,  U.  S.  P. ; 
Zn(C6H504S)2+8H20;  Zinc  SidpJiocarbolate.  It  forms  colorless, 
transparent  crystals,  odorless,  and  has  an  astringent,  metallic  taste. 
It  is  soluble  in  1.7  parts  of  water  or  alcohol. 

General  and  Local  Action. — Phenol,  when  administered  in- 
ternally in  very  diluted  form,  is  promptly  absorbed  and  exercises 
a  definite  influence  on  the  central  nerval's  system.     It  acts  as  a 


ANTISEPTICS  153 

depressing  and  stupefying  agent,  but  rarely  produces  convulsions 
in  man.  The  inspiration  and  the  heart's  action  are  accelerated 
and  the  temperature  is  slightly  decreased,  while  the  secretions  are 
increased.  The  urine  becomes  brownish-black ;  it  should  be  under- 
stood that  this  discoloration  is  not  due  to  the  presence  of  blood, 
but  is  due  to  the  phenol  administration.  Locally  applied,  phenol 
acts  as  a  general  protoplasm  poison.  Phenol  solutions  are  only 
weakly  ionized;  their  action  does  not  depend  so  much  on  the  ion, 
CgHgO,  as  on  the  whole  molecule,  CgHgOU,  and  this  is  partially 
the  reason  why  the  phenol  salts,  which  are  much  more  readily  dis- 
sociated in  solution,  are  much  less  active  antiseptically.  Phenol 
precipitates  albumins  and  proteins,  but  the  resultant  precipitate 
is  quite  different  from  that  formed  by  tannic  acid  or  the  metallic 
salts.  The  phenol  precipitate  of  albumin  is  of  a  loose,  flocculent 
nature;  it  does  not  prevent  the  further  penetration  of  the  phenol, 
and  the  latter  may  be  readily  washed  out  from  the  precipitate. 
The  question  of  phenol  coagulation  at  one  time  gave  rise  to  heated 
discussions  in  dental  circles  until  York,  in  1899,  proved  the  sound- 
ness of  the  above  mentioned  facts.  On  bacteria  the  action  of 
phenol  varies  greatly  with  the  species  of  the  micro-organisms.  The 
ordinary  pyogenic  bacteria  are  usually  readily  destroyed  by  a  3 
to  5  per  cent  solution,  while  spores  are  very  resistant  even  to  con- 
centrated solutions.  "When  applied  to  the  skin  in  concentrated 
solution,  phenol  produces  a  white  opaque  scar,  which  falls  off  in 
a  few  days,  leaving  a  light,  reddish-brown  stain,  which  may  re- 
main for  several  days,  or  even  weeks.  Even  in  weak  solution 
(5  per  cent),  when  applied  for  some  time  and  prevented  from 
evaporation,  it  may  produce  necrosis  of  the  parts.  Numbness  of 
the  covered  area,  or  even  almost  complete  anesthesia,  may  accom- 
pany the  phenol  application.  If  phenol  is  applied  to  mucous 
membranes  in  concentrated  solution,  it  produces  sloughing,  and 
acute  inflammation  may  follow.  Sometimes  general  effects  are 
observed  from  the  absorption  of  large  quantities  of  the  solution 
when  applied  locally.  Phenol  is  rather  a  poor  deodorant  as  com- 
pared with  cresol  and  similar  bodies.  It  should  be  remembered, 
however,  that  deodorization  does  not  mean  antiseptic  action. 

Therapeutics. — The  antiseptic  value  of  phenol  in  solution  de- 
pends largely  on  the  solvents  used.  If  a  chemical  is  to  penetrate 
into  the  structure  of  an  organism  (bacterium),  it  must  be  as  solu- 
ble in  the  cell  fluids  as  in  the  fluids  in  which  it  is  applied.    Koch 


154  PHARMACO-THERAPEUTICS 

pointed  out  long  ago  that  phenol  and  other  antiseptics  dissolved 
in  alcohol  and  especially  in  oil  are  practically  valueless  when  ap- 
plied as  antiseptics.  It  is  interesting  to  observe  that,  on  the  other 
hand,  the  addition  of  small  quantities  of  sodium  chlorid  to  an 
aqueous  phenol  solution  increases  its  antiseptic  action  very  mark- 
edly. Temperature  also  has  a  decided  influence  on  the  antiseptic 
action  of  phenol  solution.  Raising  the  temperature  to  120  to  140° 
F.  (50  to  60°  C.)  increases  its  disinfecting  action  very  materially 
Phenol  solutions  are  rarely  used  at  present  for  surgical  purposes; 
its  irritating  action  and  the  possibility  of  producing  necrosis  arc 
probably  the  chief  factors  of  its  elimination  from  wound  surfaces. 
As  a  gargle  from  1  to  2  per  cent  solutions  are  employed.  Carbo- 
lated  oil  or  vaselin  (5  to  10  per  cent)  are  recommended  as  lubri- 
cants for  surgical  instruments.  Liquid  phenol  is  quite  freely  used 
as  a  caustic  for  small  tumors,  gum  tissue,  fistulous  tracts,  abscess 
cavities,  etc.  Its  application  should  be  always  immediately  fol- 
lowed by  alcohol  to  limit  its  action. 

Toxicology. — Phenol  is  frequently  taken  with  suicidal  intent. 
It  is  a  most  deadly  poison;  the  lethal  dose  is  about  0.25  C.c.  of 
the  official  liquid  phenol  per  pound  of  body  weight  and  usually 
it  produces  its  effects  very  quickly.  The  presence  of  food  in  the 
stomach  greatly  increases  the  chances  of  recovery,  even  though 
a  large  quantity  of  the  poison  has  been  taken.  The  odor  of  phenol 
and  the  caustic  action  on  the  mucous  membranes  of  the  mouth 
and  the  lips  are  in  most  cases  readily  recognizable  symptoms  of 
phenol  poisoning.  The  treatment  consists  of  the  removal  of  the 
poison  with  the  stomach  tube  and  the  administration  of  demulcent 
drinks,  as  white  of  egg,  or  lime  suspended  in  sugared  water.  Ac- 
cording to  Macht,^  lavage  of  the  stomach  is  the  prime  requisite  in 
treating  phenol  poisoning.  From  experimental  study  of  the  sub- 
ject, he  reaches  the  following  conclusions : 

1.  The  efficiency  of  lavage  in  phenol  poisoning  depends  on  the 
quantity  of  poison  taken,  on  the  time  after  poisoning  that  the 
lavage  is  begun,  and  on  the  solution  used  for  washing  the  stomach. 

2.  A  strong  solution  of  sodium  sulphate  appears  to  be  the  most 
useful  for  the  purpose ;  next  in  efficiency  comes  plain  water. 

3.  The  influence  of  alcohol  in  phenol  poisoning  depends  on 


»Maclit:  The  Johns  Hopkins  Hospital   Bulletin,   Vol.   XXVI,   April,    191S. 


ANTISEPTICS  155 

the  time  of  its  administration.  An  animal  that  is  previously  in- 
toxicated with  alcohol  can  withstand  better  the  effects  of  phenol 
taken  afterwards.  On  the  other  hand,  alcohol  administered  to  an 
animal  after  poisoning  with  phenol,  will  aggravate  the  symptoms 
and  hasten  death. 

4.  The  use  of  alcohol  in  phenol  poisoning  should  therefore  be 
strongly  discouraged. 

Heat  applied  to  the  body  surfaces  and  the  judicious  use  of  gen- 
eral stimulants  are  useful  adjuncts.  As  stated  above  the  internal 
administration  of  alcohol  in  the  belief  of  forming  definite  chemic 
inert  compounds  with  phenol  is  a  mistaken  idea,  as  there  is  no 
evidence  of  chemic  antagonism  between  the  two  substances. 
Vinegar  given  in  large  quantities  has  also  proved  to  be  affective. 
Recently  tincture  of  iodin  administered  in  very  diluted  form,  one 
dram  (4  C.c.)  in  a  tumblerful  of  water,  has  been  found  to  be  ser- 
viceable. The  local  caustic  effects  of  phenol  may  be  quickly  miti- 
gated by  thoroughly  washing  the  parts  with  alcohol,  which  dis- 
solves the  phenol,  and  then  covering  the  cauterized  surfaces  with  a 
bland  ointment. 

Quite  a  large  number  of  phenol  compounds  have  been  favorites 
with  dental  practitioners.  Some  of  the  better  known  compounds, 
including  their  approximate  composition,  are  the  following: 

Solution  of  Sodium  Phenolate   (Phenol  Sodique). 

I^     Phenol  crystals  S  j    (30  Gm.) 

Sodium  hydrate  3  ss   (2  Gm.) 

Water  5  j   (30  C.c.) 

Dissolve  the  sodium  hydrate  in  the  water,  add  the  phenol, 

and  warm  gentlj'. 

Camphorated  Phenol;  Carbolated  Camphor;  Campho- 
Phenique. 

A  solution  of  camphor  and  phenol  in  liquid  petrolatum.  It  is  a 
simple  solution  of  the  two  components  and  not,  as  it  has  been 
claimed,  a  new  chemic  compound.  It  is  much  less  caustic  than 
liquid  phenol,  the  camphor  and  the  liquid  petrolatum  act  as  sol- 
vents and  diluents  of  the  phenol  and  prevent  its  ready  action  on  the 
tissues. 


1 56  PHARMACO-THERAPEUTICS 

B.     Phenol  crystals  3  ij    (8  Gm.) 

Camphor  3  iv  (16  Gm.) 

Liquid  petrolatum  fl3  iv   (16  C.c.) 

Place  the  components  in  a  dry  bottle,  and  within  a  few 
hours  they  will  form  a  homogeneous  liquid. 

A  more  effective  and  widely  used  substitute  has  the  following 
composition : 

U     Phenol  crystals  5  j    (30  Gm.) 

Camphor  5  ij    (60  Gm.) 

Alcohol  fl3  iiss  (10  C.c.) 

Prepare  as  directed  above. 

Phenolated  Thymol;  Thymol-Camphene. 

A  solution  of  phenol,  thymol,  and  camphor.  It  is  much  lauded 
in  the  treatment  of  putrescent  root  canals. 

IJ     Phenol  crystals  3  ij   (8  Gm.) 

Thymol  3  ij   (8  Gm.) 

Camphor  3  j    (4  Gm.) 

Place  the  components  in  a  dry  bottle,  and  within  a  few 
hours  they  will  form  a  homogeneous  liquid. 

Black's  1-2-3. 

R     Oil  of  cassia  fl3  j   (4  C.c.) 

Phenol  crystals  3  ij   (8  Gm.) 

Oil  of  wintergreen  fl3  iij   (12  C.c.) 

Mix  the  oils  and  add  the  melted  crystals  of  phenol. 

Arkovy's  Mixture. 

H     Phenol  crystals  3  ij   (8  Gm.) 

Camphor  3  j   (4  Gm.) 

Oil  of  eucalyptus  fl3  j   (4  C.c.) 

MONOCHLOROPHENOL ;  PaRA-MONO-CHLORO-PHENOL  ; 

CeH,Cl(OH). 

A  product  of  chlorin  substitution,  replacing  one  or  more  hydro- 
gen atoms  of  phenol.  It  appears  in  colorless  crystals,  very  soluble 
in  ether  and  alkalies,  less  soluble  in  water.  In  many  respects  it 
acts  like  phenol,  but  it  is  much  more  poisonous  to  micro-organ- 
isms. It  possesses  very  strong  disinfecting  properties,  and  has 
a  great  power  of  penetration.     It  acts  as  a  valuable  obtundent. 


ANTISEPTICS  157 

Walkhoff,  Romer,  Dorn,  Michel,  and  others  have  lauded  its  value 
in  the  treatment  of  pyorrhea  alveolaris. 

Creosote;    Creosotum,    U.  S.  P.,  B.  P.;  Beechwood    Creosote; 

Oil  of  Smoke. 

Source  and  Character. — Creosote  is  a  mixture  of  phenols  and 
phenol  derivatives,  chiefly  guaiaeol  and  cresol,  obtained  from  wood 
tar,  preferably  from  beech  tar.  It  is  an  almost  colorless,  yellow- 
ish oily  liquid,  with  a  smoky  odor  and  a  burning,  acrid  taste.  It 
is  soluble  in  about  140  parts  of  water  at  ordinary  temperature, 
readily  soluble  in  alcohol,  ether,  chloroform,  and  fixed  or  es- 
sential oils. 

Average  Dose. — 3  minims  (0.2  C.c). 

Therapeutics. — Creosote  was  introduced  into  dentistry  soon 
after  its  discovery  by  Reichenbach  (1830),  and  it  at  one  time  oc- 
cupied a  very  prominent  place  in  dentistry,  being  the  most  im- 
portant antiseptic  used  for  the  treatment  of  diseases  of  the  pulp. 
At  present  it  is  obsolete,  and  phenol,  cresol,  and  the  many  modern 
antiseptics  have  taken  its  place.  Creosote — that  is,  beechwood 
creosote — should  not  be  confounded  with  coal  tar  cresote,  a  sub- 
stance prepared  from  coal  tar.  The  latter  is  of  a  different  compo- 
sition and  poisonous,  and  should  not  be  substituted  for  beech- 
wood creosote. 

Guaiacol;  Guaiacol,  U.  S.  p.;  C^HgOg. 

It  is  one  of  the  principal  products  of  beechwood  creosote,  or  pre- 
pared synthetically.  It  is  a  colorless  crystalline  solid,  melting  at 
about  85°  F.  (30°  C),  or  a  colorless  refractive  liquid,  having  an 
agreeable  aromatic  odor.  It  is  soluble  in  about  55  parts  of  water, 
in  alcohol,  ether,  and  glycerin. 

Guaiacol  Carbonate,  U.  S.  P.,  also  known  as  duotal,  is  a  deriva- 
tive of  the  above  compound.    Average  dose,  8  minims  (0.5  Gm.). 

Cresol;  Cresol,  U.  S.  P.;  C^H^.OH;  Tricresol. 

Source  and  Character. — Cresol  presents  a  mixture  of  three 
isomeric  cresols  obtained  from  ^oal  tar,  freed  from  phenol,  hydro- 
carbons, and  water.  Commercially  the  mixture  is  known  as 
tricresol.  It  is  a  straw-colored  reactive  liquid,  having  a  phenol- 
like odor  and  turning  brown  on  prolonged  exposure  to  light. 
Cresol  is  soluble  in  60  parts  of  water  at  ordinary  temperature,  and 


1 58  PMAUMACO-TIlIiUAPlSUTlcg 

it  is  iniseible  with  alcohol,  ether,  <?lyccriii,  and  alkali  hydroxid 
solution.  By  fractional  distillation  the  following  constituents  are 
obtained : 

Orthocresol,  at  about  371°  F.  (188°  C),  colorless  crystals.  (35 
per  cent.) 

Paracresol,  at  about  389°  F.  (198°  C),  cr^-stalline  masses.  (25 
per  cent.) 

Metacresol,  at  about  394°  F.  (201°  C),  light-yellowish  liquid. 
(40  per  cent.) 

Kresamin  is  the  name  given  to  a  clear  watery  solution  of  25 
per  cent  of  tricresol  and  25  per  cent  of  ethylen-diamin. 

Average  Dose. — 1  minim  (0.05  C.c). 

Therapeutics. — Cresol  is  a  strong  antiseptic,  resembling  close- 
ly phenol  in  its  general  action.  It  is  said  to  be  about  three  to  four 
times  as  strong  as  phenol,  but  less  poisonous.  ]\Ietacresol  is  by 
far  the  most  active  of  the  cresols.  The  cresols  are  principally  used 
as  external  antiseptics  and  as  germicides.  Like  all  phenols,  they 
act  as  local  obtundents.  The  cresols  are  soluble  in  solutions  of 
certain  organic  substances — in  soap  solution  and  other  alkaline 
solutions.    The  most  important  representative  of  this  group  is: 

Compound  Solution  of  Cresol;  Liquor  Cresolis  Compositus,  U. 
S.  P. ;  Lysol.  It  is  a  50  per  cent  solution  of  cresol  in  a  linseed 
oil  soap ;  it  mixes  freely  with  Avater,  forming  a  clear  solution, 
which  is  very  soapy  in  its  nature.  Solveol  and  solutol  are  similar 
compounds,  while  creolin  is  an  emulsion  of  cresols  with  resin  soap. 

Resorcinol  ;  Resorcinol,  U.  S.  P. ;  CeHgOo. 

Synonyms. — Resorcin,  metadioxybenzol. 

Source  and  Character. — A  neutral  or  slightly  acid  diatomic 
phenol  obtained  from  benzol  by  various  processes.  It  is  found 
in  galbanum,  asafetida,  ammoniac,  and  other  gum  resins.  It  ap- 
pears in  colorless  or  slightly  pinkish  crystals,  having  a  faint  odor 
and  a  sweetish,  disagreeable  taste.  It  is  soluble  in  0.5  parts  of 
water  or  alcohol,  readily  soluble  in  ether  and  glycerin  and  melts 
at  about  248°  F.  (120°  C).  It  is  incompatiUe  with  ferric  salts 
and  bromin  water. 

Average  Dose. — 2  grains  (0.125  Gm.). 

Medical  Properties. — Antiseptic  and  disinfectant;  internally, 
antipyretic. 

Therapeutics. — Resorcinol  is  much  lauded  as  an  antiseptic  for 


ANTISEPTICS  159 

the  oral  cavity.  A  2  per  cent  aqueous  solution,  flavored  with  an 
essential  oil,  may  be  used  with  impunity  as  a  mouth  wash.  While 
resorcinol  seems  to  be  as  antiseptic  as,  or  even  more  strongly  anti- 
septic than,  phenol,  it  is  at  present  seldom  employed  as  a  sub- 
stitute for  the  latter.  In  the  form  of  an  ointment  (5  to  10  per 
cent)  it  is  much  used  in  skin  diseases. 

Compound  Resorcinol  Ointment. 

IJ     Resorcinol  3  jss   (6  Gm.) 

Zinc  oxid  3  jss   (6  Gm.) 

Bismuth  subnitiate  3  jss   (6  Gm.) 

Oil  of  cade  3  iij   (12  C.c.) 

Petrolatum  3  ijss   (10  Gm.) 

Hydrous  woolfat  S  j    (35  Gm.) 
Make  into  an  ointment. 

Benzoic  Acid;  Acidum  Benzoicum,  U.  S.  P.,  B.  P.;  HCJIr.Oa- 

Synonyms. — Flowers  of  benzoin ;  acide  benzoique,  B. ;  Benzoe- 
saure,  Gr. 

Source  and  Character. — An  organic  acid  obtained  from  ben- 
zoin by  sublimation,  or  prepared  artificially,  usually  from  toluol. 
It  may  be  prepared  also  from  hippurie  acid  and  other  organic 
compounds.  It  appears  in  light,  feathery  needles,  having  a  slight- 
ly aromatic  odor  and  a  warm,  acid  taste.  It  is  soluble  in  about  281 
parts  of  water  and  15  parts  of  boiling  water,  readily  soluble  in 
alcohol,  ether,  and  in  fixed  or  volatile  oils.  Its  solubility  in  water 
is  much  increased  by  the  addition  of  borax  or  other  alkalies.  It 
is  mcompatihle  with  mercuric  chlorid  and  many  of  the  other  metal- 
lic salts.  Benzoic  acid  should  be  preserved  in  amber-colored  bot- 
tles. 

Average  Dose. — 7i/^  grains  (0.5  Gm.). 

Medical  Properties. — Antiseptic,  disinfectant,  and  antipyretic. 

Therapeutics. — A  1  per  cent  solution  of  benzoic  acid  will  tem- 
porarily sterilize  the  oral  cavity  in  about  half  a  minute.  (Miller.) 
It  is  preferable  in  many  respects  over  thymol,  phenol,  and  similar 
preparations  as  an  effective  constituent  of  mouth  washes.  It  is 
almost  nonpoisonous,  and  has  no  irritating  effect  on  the  mucous 
membrane.  Tooth  structure  is  apparently  not  affected  by  benzoic 
acid.  Internally,  benzoic  acid  and  its  salts  are  administered  to 
increase  the  amount  of  expectoration  by  stimulating  the  secretions 
and  the  respiratory  organs. 


160  PHARMACO-THERAPEUTICS 

Myrrh.    Myrriia.    U.  S.  P.,  B.  P. 

It  is  a  solid  gum  resin  obtained  from  Commiphora  Myrrha  and 
contains  a  small  quantity  of  essential  oil.  In  the  form  of  its  tinc- 
ture, a  20  per  cent  solution  in  alcohol,  it  has  been  lauded  in  the 
past  as  a  veritable  panacea  in  all  diseases  of  the  oral  cavity.  At 
present  it  is  obsolete. 

Salicylic  Acid;  Acidum  Salicylicum,  U.  S.  P.,  B.  P.; 
HC7H5O3. 

Synonyms. — Ortho-oxybenzoic  acid ;  acide  salicylique,  F. ; 
Salicylsaure,  G. 

Source  and  Character. — Salicylic  acid  has  been  known  since 
1834  to  exist  in  the  form  of  an  aldehyd  (salicin)  in  many  plants, 
especially  in  the  oils  of  wintergreen,  sweet  birch,  willow  bark,  etc. 
At  present  it  is  usually  prepared  synthetically.  Salicylic  acid 
appears  in  light,  fine  white  needles;  it  is  odorless,  having  a  sweet- 
ish, afterward  acrid,  taste.  It  is  soluble  in  about  310  parts  of 
cold  and  in  14  parts  of  boiling  water,  in  2  parts  of  alcohol,  in  80 
parts  of  glycerin,  and  in  ether  and  chloroform.  It  is  incompati- 
ble with  ferric  salts,  quinin,  and  spirit  of  nitrous  ether. 

Average  Dose. — 714  grains  (0.5  6m.). 

IMedical  Properties. — Antipyretic,  antiseptic,  antirheumatic, 
and  anhidrotic. 

Preparations. — 

Phenyl  Salicylate;  Fhenylis  Salicylas,  U.  S.  P. ;  Salol,  B.  P. ; 
CiaHioOg.  Salol  is  prepared  by  the  interaction  of  a  sodium  salt 
of  salicylic  acid  and  phenol  with  phosphoryl  chlorid.  It  appears 
as  a  white  crystalline  powder,  with  a  faintly  aromatic  odor  and 
little  taste.  It  is  freely  soluble  in  ether  and  alcohol,  almost  in- 
soluble in  water.     Average  dose,  7i/^  grains  (0.5  Gm.). 

Sodium  Salicylate;  Sodii  Salicylas,  U.  S.  P.,  B.  P. ;  NaC^HgOg. 
Sodium  salicylate  is  a  white  odorless  powder,  with  a  sweetish, 
saline  taste;  it  is  very  soluble  in  water.  Average  dose,  15  grains 
(1  Gm.). 

Aspirin;  Acetylsalicylic  Acid.  It  is  a  white  powder,  slightly 
soluble  in  water,  but  readily  soluble  in  alcohol.  It  has  a  very 
slightly  acid  taste.  It  has  a  well-earned  reputation  as  an  anal- 
gesic.   Average  dose,  71/^  grains  (0.5  Gm.). 

Therapeutics. — As  salicylic  acid  is  only   sparingly   soluble   in 


ANTISEPTICS  161 

watrr,  it  is  seldom  employed  as  an  antiseptic,  although  it  is  almost 
equal  in  strength  to  phenol.  It  is  extensively  used  as  a  surgical 
dressing  in  the  form  of  cotton  wool  impregnated  with  the  acid. 
Formerly  it  was  highly  praised  as  a  mouth  wash  in  alcoholic 
solution.  Salicylic  acid  acts  very  deleteriously  on  tooth  structure, 
and  even  in  Yiq  per  cent  solution  it  will  affect  the  enamel.  Its 
sodium  salt  is  used  as  a  specific  for  acute  rheumatism ;  it  reduces 
the  temperature  and  the  pain,  and  removes  the  local  symptoms 
of  this  disease.  Aspirin  and  similar  preparations  have  largely 
supplanted  the  use  of  salicylic  acid  and  sodium  salicylate. 

Salol  is  the  principal  constituent  of  a  much  advertised  proprie- 
tary mouth  wash;  it  is  broken  up  by  the  saliva  into  its  compo- 
nents— salicylic  acid  and  phenol — and  is  as  detrimental  to  the 
enamel  of  the  teeth  as  salicylic  acid  alone.  The  prolonged  use 
of  a  salol  solution  as  a  mouth  wash  is  very  apt  to  produce  mor- 
billiform eruptions  about  the  lips,  especially  about  the  corners 
of  the  mouth,  which  are  known  as  "mouthwash  eczema." 

Chinosol  ;  Chinosol  ;  CgHgN.KSO^. 

Synonyms. — Potassium  oxyehino-sulphate ;  oxychinolin  alum. 

Source  and  Character. — Chinosol  is  obtained  from  the  inter- 
action of  oxychinolin  (chinophenol)  and  potassium  pyro-sulphate 
in  alcoholic  solutions.  It  occurs  in  the  form  of  a  crystalline 
lemon-yellow  powder,  having  a  pleasant  aromatic  odor  and  an 
astringent  taste.  It  is  very  freely  soluble  in  water;  insoluble  in 
alcohol  and  ether.  It  is  incompatible  with  the  alkaline  salts  and 
the  salts  of  iron.  Steel  instruments  will  be  blackened,  but  not 
corroded,  when  brought  in  contact  with  it;  the  stain  is  easily 
removed  by  polishing  with  an  abrasive. 

Medical  Properties. — Antiseptic,  styptic,  and  antipyretic. 

Therapeutics. — Administered  internally,  chinosol  acts  as  a 
prompt  antipyretic  and  intestinal  antiseptic.  It  is  lauded  as  a 
specific  in  influenza  and  general  "colds."  Externally  applied,  it 
is  a  very  efficient  nontoxic  antiseptic.  It  is  claimed  that  its  germi- 
cidal power  is  in  many  respects  equal  to  that  of  mercuric  chlorid. 
ft  does  not  coagulate  albumin,  is  very  diffusible,  and  has  no 
caustic  effect  on  tissues.  Grunert,  in  1895,  introduced  it  into  den- 
tistry, and  called  special  attention  to  its  great  deodorizing  power 
and  its  destructive  effects  on  pus  micro-organisms.  Bohm,  Oook, 
MaWhinney,  and  others  have  lauded  it  very  highly  as  an  oral 


162  PH  ARM  A  CO-THERAPEUTICS 

antiseptic.  As  a  general  antiseptic,  aqueous  Yio  per  cent  solu- 
tions are  usually  employed.  For  injection  into  pus  cavities,  1  or 
2  per  cent  solutions  are  recommended.  Good  results  are  obtained 
with  it  in  the  form  of  weak  solutions  and  as  gauze  packings  in 
the  treatment  of  empyema  of  the  antrum.  Prolonged  use  in  the 
mouth  slightly  darkens  the  teeth. 

Chinosol  has  been  recently  reintroduced  into  dentistry  in  tablet 
form  under  the  name  of  Keys- All;  each  tablet  contains  1  grain 
(0.06  Gm.). 

Betanaphthol  ;  Betanaphthol,  U.  S.  p.  ;  CioH^OH ;  Naphthol. 

Source  and  Character. — A  monatomic  phenol  occurring  in 
coal  tar,  but  usually  prepared  from  naphthalene.  It  appears  as  a 
pale  buff  colored,  shiny  crystalline  powder,  having  a  faint  phenol- 
like odor  and  a  sharp,  pungent  taste.  It  is  soluble  in  about  950 
parts  of  water,  very  soluble  in  alcohol  and  ether.  Hydronaphthol, 
a  proprietary  preparation,  is  claimed  to  be  an  impure  beta- 
naphthol. 

Average  Dose. — 4  grains  (0.25  Gm.). 

Medical  Properties, — Antiseptic  and  disinfectant. 

Therapeutics. — Alcoholic  solutions  of  betanaphthol  in  various 
concentrations  are  recommended  as  mouth  washes,  especially  in 
pyorrhea  alveolaris. 

Betanaphthol  Mouth  Wash. 

IJ     Betanaphthol  gr.  xv  (1  Gm.) 

Alcohol. 
Glycerin. 
Aquae  aa  flg  j   (30  C.c.) 

M. 

Sig. :    Half  teaspoonf ul  in  a  small  glass  of  warm  water,  to 
be  used  twice  a  day.     (James  Truman.) 

Antiseptic  Cavity  Varnish. 

R     Select  gum  copal  3  x  (40  Gm.) 

Ether  flS  jss  (45  C.c.) 

Betanaphthol  3  j   (4  Gm.) 

Sig. :    Dissolve  the  copal  and  the  betanaphthol  in  the  ether, 
filter  through  a  well-covered  filter,  and  add  enough  ether  to 
make  the  whole  measure  2  ounces  (60  C.c).     Keep  in  well- 
,  ,  r  stoppered  bottles. 


ANTISEPTICS  163 

Balsam  of  Peru  ;  Balsamum  Peruvianum,  U.  S.  P.,  B.  P. ; 
Baume  des  Indes,  F.  ;  Peruvianischer  Balsam,  G. 

Source  and  Character.— Balsam  of  Peru  is  obtained  from 
Toluifera  Pereirce,  Bailton,  family  Leguminosm,  a  tree  growing  in 
El  Salvador.  It  is  a  thick,  viscid  liquid,  having  a  brown  color 
and  an  agreeable  vanilla-like  odor.  Its  taste  is  of  a  bitter,  acrid 
nature  and  very  persistent.  It  is  completely  soluble  in  absolute 
alcohol,  chloroform,  and  glacial  acetic  acid,  partially  soluble  in 
';ther,  and  soluble  in  5  parts  of  alcohol.  Water,  when  agitated 
with  the  balsam,  shows  an  acid  reaction  to  blue  litmus  paper. 
Balsam  of  Peru  consists  of  65  per  cent  of  perubalsam  oil,  known 
as  cinnamen,  of  vanillin,  cinnamic  acid,  and  about  35  per  cent  of 
resinous  substances.  The  balsam  is  quite  frequently  sophisti- 
cated with  cheaper  balsams  and  essential  oils. 

Average  Dose. — 5  to  30  minims.  (0.3  to  2  C.c). 

Therapeutics. — Balsam  of  Peru  enjoys  quite  a  reputation  in 
the  treatment  of  skin  diseases.  Recently  Suter^  tested  its  anti- 
septic qualities,  and  found  that  the  viscid  balsam  is,  in  a  certain 
sense,  a  reservoir  of  bactericidal  substances,  which  gradually  dif- 
fuse to  the  surrounding  medium  and  which  mechanically  and 
chemically  interfere  with  the  growth  of  bacteria.  It  also  pos- 
sesses chemotaetie  properties.  Mayrhofer^  recommends  the  bal- 
sam very  highly  as  the  ideal  root  filling  material  in  asepticized 
canals.  He  injects  the  balsam  with  a  small  syringe  and  covers  it 
with  cement  or  amalgam.  He  claims  that  balsam  of  Peru  is  a 
very  persistent  antiseptic,  which  fills  every  nook  of  the  root  canal 
and  does  not  change  its  volume,  nor  does  it    discolor    the    tooth. 

Some  years  ago  a  preparation  known  as  "balsamo  del  deserto, " 
which  resembled  balsam  of  Peru  to  some  extent,  was  much  lauded 
as  a  root  filling  material.  At  present  it  is  apparently  little  used. 
Other  balsams  and  balsamic  resins — as  balsam  of  Tolu,  styrax, 
benzoin,  etc. — are  seldom  employed  in  their  pure  state  as  anti- 
septics. 

Trinitrophenol  ;   Trinitrophenol,  U.   S.  p.  ;   CgHaO^N^ ;   Picric 
Acid;  Picronitric  Acid. 

It  occurs  in  yellow,  lustrous  crystals,  odorless,  and  having  an 
intense  bitter  taste.    It  is  soluble  in  10  parts  of  alcohol,  6.5  parts 


'  Suter:  In  Prinzipien  der  Pulpagangran,  by  Mayrhofer,  1909. 
'Mayrhofer:  See  Suter. 


1G4  IMIARMACO-THERAPEUTICS 

of  ether,  and  170  parts  of  water.  It  is  readily  oxidized,  and  forms 
dangerous  compounds  when  mixed  with  sulphur,  phosphorus,  etc. 
It  should  never  be  applied  in  substance.  It  is  claimed  that  a 
hydro-alcoholic  solution  of  picric  acid  is  extremely  useful  in  all 
forms  of  burns. 

Solution  for  Burns. 

IJ     Acid,  picric.  3  iss   (6.0  Gm.) 

Alcohol  flS  ij    (60  C.c.) 

Aq.  destillat.  ad  flj  xxxij   (1,000  C.c.) 

M. 

Sig. :      Strips  of  lint  are   soaked   in   this   solution,  placed 
over  the  burned  surface  and  kept  moist  with  it. 

Anilin  Dyes. 

A  group  of  compounds  of  the  aromatic  series  commercially 
known  as  anilin  dyes  and  which  are  primarily  employed  in  the  in- 
dustries and  as  staining  media  for  the  identification  of  tissues, 
have  also  proved  to  be  of  value  as  therapeutic  agents.  According 
to  Stilling,  these  dyes  are  non-poisonous,  they  are  readily  soluble, 
they  diffuse  deeply  into  the  tissues,  they  do  not  coagulate  albumin 
and  they  possess  germicidal  action.  The  principal  representatives 
are  methylene  blue,  methylene  violet,  and  scarlet  red  and  its  color- 
less modifications. 

Methylene  Hydrochlorid,  IMethylene  Blue,  U.   S.   P., 
C\,H,sN3SCl. 

It  is  obtained  by  the  action  of  hydrogen  sulfid  upon  an  oxidation 
product  of  para-amino-dimethyl-anilin.  It  is  a  dark  green,  crystal- 
line powder,  readily  soluble  in  water,  somewhat  less  soluble  in  al- 
cohol, the  solution   having  a  deep  blue  color. 

Methylene  violet,  known  as  pyoktanin  and  methylene  yellow, 
known  as  auramin,  are  modifications  of  methylene  blue.  Thej^  are 
soluble  in  about  75  parts  of  water,  in  alcohol,  etc.  These  various 
dyes  have  been  lauded  in  the  treatment  of  the  ulcerative  forms  of 
stomatitis,  especially  the  tubercular  types,  Vincent's  angina  and 
similar  disturbances  of  the  oral  cavity.  The  dyes  may  be  dusted 
over  the  diseased  surfaces  in  substance  or  applied  with  a  swab  in 
10  per  cent  solutions. 

Scarlet  Red,  Biebrich. 
It  is  a  diazotised  amino-azo-ortho-toluol  Avith  betanaphthol.    It 


ANTISEPTICS  165 

is  a  dark  reddish-brown  powder,  insoluble  in  water,  soluble  in  al- 
cohol, ether,  chloroform,  fats  and  fatty  oils.  An  almost  colorless 
modification  of  scarlet  red,  possessing  the  same  characteristics,  is 
known  as  dimazon  or,  in  continental  Europe,  as  pellidol.  Scarlet 
red  exercises  a  most  beneficial  influence  on  the  new  formations  of 
epithelium  over  denuded  surfaces  when  applied  in  the  form  of  a 
5  to  8  per  cent  ointment.  Schmieden  introduced  this  "scarlet 
salve"  for  the  purpose  of  inducing  fresh  granulation  and  the  re- 
sults obtained  are  most  gratifying.  The  ointment  is  spread 
thinly  on  the  dressing  material  and  covered  by  cotton  or  lint  to 
prevent  staining  of  the  linen.  If  a  less  highly  colored  prepara- 
tion is  desired,  dimazon  ointment  may  be  substituted. 

Antiseptics  of  the  Marsh  Gas  Series. 

Marsh  gas  (methan,  CIT4)  furnishes  the  basic  radical  of  a  very 
large  group  of  organic  compounds  that  have  been  used  with  re- 
markable success  in  therapeutics.  The  vast  majority  of  these 
compounds  are  characterized  by  a  depressing  action  on  the  nerv- 
ous system.  The  hydroxyl  compounds  of  certain  derivatives  of 
methan  are  knowii  as  alcohols.  The  simplest  form  is  methyl  alco- 
hol, CH3OH,  a  product  of  oxidation  of  methan.  Methyl  alcohol 
is  rarely  used  as  an  antiseptic,  and  Avh^^n  further  oxidized  it  pro- 
duces a  gaseous  aldehyd,^  CHaO+H^O,  known  as  formaldehyd, 
according  to  the  following  equation : 

CH30H+0=CHoO-fH20. 

This  latter  compound  is  one  of  the  most  powerful  disinfectants 
at  our  command.  By  substituting  one  H-atom  of  methan  by  the 
molecule  CH3,  a  second  i-adical  of  marsh  gas  is  produced  known 
as  ethan,  CoH,,.  If  one  H-atom  of  ethan  is  replaced  by  the  hy- 
droxjd  group,  OH,  ethyl  alcohol,  C^H.OH,  is  obtained.  By  further 
increased  substitutions  of  the  H-atom  of  methan,  a  number  of 
higher  alcohols — such  as  the  propyl,  butyl,  and  amyl  alcohols — yrc 
obtained.     Their  therapeutic  application  is  very  limited. 

Solution  of  Formaldehyd  ;  Liquor  Formaldehydi,  U.  S.  P. : 
Formalin;  Formol;  Formicaldehyd ;  Oxymethylen. 

Source  and  Character. — An  aqueous  solution  of  not  less  than 
37  per  cent  of  absolute  formaldehyd  (H.CO.H.).     It  is  an  oxida- 

'  An  aldehyd  is  a  dchyilrogonated  alcohol. 


166  PHARMACO-THERAPEUTICS 

tion  product  of  methyl  alcohol.  Water  will  take  up  about  52  per 
cent  of  formaldehyd  gas,  but  it  will  not  retain  more  than  35  to  40 
per  cent  at  ordinary  temperature.  On  standing,  slight  separa- 
tion of  paraformaldehyd  takes  place.  It  is  a  clear,  colorless  liquid, 
having  a  pungent  odor  and  a  caustic  taste.  Its  vapors  are  very 
irritating  to  the  mucous  membrane.  It  is  readily  miscible  with 
water  and  alcohol,  and  its  fresh  solutions  react  neutral  or  faintly 
acid  to  litmus  paper.  It  is  in€07npatihle  with  ammonia,  alkalies, 
tannic  acid,  gelatin,  iron  preparations,  and  the  salts  of  copper, 
iron,  or  silver. 

Preparations, — 

Paraformaldehydum,  TJ.  S.  P.;  Trioximethylen;  Paraformalde- 
hyd. It  is  prepared  by  polymerizing  formic  aldehyd  by  heat.  It  is 
a  white  crystalline  powder,  very  slowly  soluble  in  water,  alcohol,  or 
ether,  and  melting  at  340°  F.  (171°  C).  At  ordinary  temperature 
it  gives  up  formaldehyd  vapors,  which  are  readily  increased  by  heat. 
Paraform  is  largely  used  for  disinfecting  purposes,  and  forms  an 
important  component  of  the  many  mummifying  pastes  that  are  em- 
ploj^ed  for  the  preservation  of  pulp  stumps  left  in  root  canals. 

Phenyform.  Is  a  condensation  product  of  phenol  and  formal- 
dehyd. It  is  a  grayish-white  powder,  devoid  of  odor,  soluble  in 
alkalies  and  alcohol,  but  insoluble  in  water  or  ether.  In  the 
presence  of  animal  secretions  and  tissue  fluids  it  splits  up  into  its 
components.  It  has  been  used  to  some  extent  as  a  wound  anti- 
septic. 

Hexamethylenamin;  HexametTiylenamina,  U.  S.  P. ;  Urotropin; 
Aniinoform;  Formin;  Cystogen.  A  condensation  product  ob- 
tained by  the  action  of  ammonia  on  formaldehyd.  It  is  soluble  in 
1.5  parts  of  water  and  in  10  parts  alcohol.  Average  dose,  4  grains 
(0.25  Gm.). 

Formamint.  A  mixture  of  formaldehyd  and  sugar  of  milk 
and  compressed  into  small  tablets  containing  li/o  grains  (0.01  Gm.) 
of  active  formaldehyd,  flavored  with  menthol,  citric  acid,  etc. 
The  tablets  are  dissolved  in  the  mouth,  and  thus,  it  is  claimed,  a 
slow,  continuous  action  of  formalin  is  obtained. 

Ly  so  form;  Veroform.  The  liquid  has  comparatively  little  of 
the  formaldehyd  odor,  and  is  much  less  irritating.  It  is  a  useful 
agent  for  disinfecting  hands,  instruments,  etc. 


ANTISEPTICS  167 

Formagen.  A  dental  cement,  containing  formalin.  It  is  used 
for  the  purpose  of  filling  root  canals,  etc. 

Cresol-Formotliymol.  A  liquid  compound  prepared  by  dissolv- 
ing thymol  in  an  alcoholic  solution  of  formaldehyd  gas,  to  which 
20  per  cent  of  eresol  is  added.  It  is  used  as  a  substitute  for  the 
cresol  formalin  mixture. 

General  and  Local  Action. — The  vapors  of  formaldehyd  are 
intensely  irritating  to  the  mucous  membrane,  the  eyes,  etc.  Taken 
internally,  it  produces  severe  gastro-enteritis,  followed  by  collapse 
and  death  in  a  very  short  time.  Two  ounces  of  commercial  formal- 
dehyd solution  are  known  to  have  killed  a  man. 

Locally  applied  in  diluted  solutions,  it  roughens  the  skin,  and 
concentrated  solutions  tan  the  skin  to  such  an  extent  that  the 
superficial  layers,  which  have  changed  to  a  horny  material,  may 
be  removed  in  shreds.  If  the  ear  of  a  living  rabbit  is  thoroughly 
painted  with  a  formaldehyd  solution  for  some  time,  it  becomes 
mummified  and  may  be  readily  broken  off.  Meats  (hams,  sau- 
sage, etc.)  treated  with  formaldehyd  become  hard  as  rock,  and 
consequently  this  compound  can  not  be  used  as  a  preservative  of 
food  stuffs.  Its  use  as  a  preservative  of  milk  is  prohibited  in 
many  cities  and  states.  For  the  preservation  of  physiologic  and 
pathologic  specimens  it  is  serviceable,  as  it  does  not  change  the 
normal  color  of  the  tissues.  On  the  mucous  membrane  formalde- 
hyd, even  when  applied  in  very  diluted  solutions,  acts  as  an  ir- 
ritant, and  in  concentrated  solution  it  acts  as  a  powerful  caustic. 
Consequently  formaldehyd  should  not  be  used  as  a  component  of 
mouth  washes,  and  the  many  proprietary  preparations  that  con- 
tain it  should  not  be  continuously  employed,  as  they  tan  the  oral 
linings  and  thus  lessen  their  resistance. 

Formaldehyd  is  a  very  powerful  germicide.  According  to 
Loew  its  bactericidal  action  on  micro-organisms  and  their  prod- 
ucts is  believed  to  be  due  to  its  affinity  for  certain  amino  groups 
in  the  proteins.  When  formaldehyd  is  added  to  a  solution  of  al- 
bumin or  serum,  a  peculiar  chemic  compound,  known  as  protagen, 
results  that  is  not  precipitated,  nor  are  the  albumins  so  treated 
precipitated  by  heat.  Applied  in  vapor  form,  it  is  one  of  the  most 
certain  means  of  disinfecting  rooms  and  their  contents. 

Recently  Buckley  has  lauded  dry  formaldehyd  (trioxymethylen) 
in  the  form  of  a  paste^  as:  "A  new,  safe  and  reliable  remedy  for 

»  Buckley:  Items  of  Interest,  December,  1914. 


168  PHARMACO-THERAPEUTICS 

hypersensitive  dentin."     This  paste  essentially  consists  according 
to  his  formula,  of: 

IJ     Neothesin  3  gr.   (0.18  Gm.) 

Thymol  3^  gr.   (0.21  Gm.) 

Trioxymethylen  21  gr.   (1.26  Gm.) 

Vaselin         q.  s.  to  make     1  dram   (4  Gm.) 

The  empirically  compounded  paste  further  contains  "a  fibrous 
vehicle  and  colored  with  an  insoluble  pigment."  These  latter  sub- 
stances play  no  part  in  the  therapeutic  action  of  the  compound. 
International  dental  literature-  of  the  last  decade  is  filled  with  ref- 
erences relative  to  the  use  of  formaldehyd  as  a  desensitizing  agent 
and  all  writers,  except  Buckley,  agree  that  it  is  a  most  dangerous 
agent  for  this  purpose,  as  it  will  injure  and,  in  most  instances,  kill 
the  pulp.  It  produces  numbness  of  dentin  in  the  same  manner  as 
arsenic,  only  acting  somewhat  slower.  Trioxymethlen  is  the  only 
active  ingredient  of  the  paste  when  employed  for  the  above  pur- 
pose; it  does  not  possess  any  local  anesthetic  properties  but  acts 
as  a  caustic  which  is  absolutelj"  non-self-limiting  and  w^hich  pene- 
trates comparatively  quickly  through  any  thickness  of  dentin.  In 
the  routine  application  of  the  paste  there  is  always  danger  of  in- 
juring the  pulp ;  the  severity  of  this  danger  increases  proportion- 
ally with  the  ready  penetration  of  the  liberated  formaldehyd  gas. 
Experimental  work  and  increasing  reports  of  deaths  of  pulps  from 
the  application  of  the  paste  renders  this  agent  absolutely  unsafe 
for  the  purpose  in  view.  As  an  illustration  of  its  intense  caustic 
action  it  may  be  stated  that  in  the  hands  of  some  practitioners  the 
Buckley  desensitizing  paste  constitutes  at  present  the  routine  ap- 
plication for  the  purpose  of  painlessly  ( ?)  killing  the  pulps  in 
deciduous  teeth. 

Formalin  Dermatitis.  Since  the  introduction  of  formaldehyd  in 
medicine  and  dentistrj*,  a  number  of  cases  of  formalin  dermatitis 
have  been  reported  in  current  literature,  occurring  especially 
among  dental  practitioners  and  workers  in  medical  laboratories, 
which,  on  account  of  their  obstinacy  to  treatment  have  given  rise 
to  much  discomfort  to  the  patient.  The  disease  is  probably  result- 
ing from  a  lessened  resistance  of  the  patient  to  the  continuous  ex- 
posure to  the  drug  and  not  so  much  from  a  general  predisposition. 
Dentists  are  frequently  in  the  habit  of  removing  with  their  fingers 

*Prinz:  Dental  Cosmos,  August,  1915. 


ANTISEPTICS  169 

cotton  fibers  which  have  been  charged  with  formocresol  from  a 
broach.  As  a  consequence  the  irritating  action  of  the  formalin 
soon  manifests  itself  in  a  persistent  and  most  painful  itching  of 
the  finger  tips,  cracking  of  the  skin,  and  bulbous  eruptions  within 
the  affected  areas,  which  frequently  involve  the  nail  folds.  If 
once  acquired,  there  is  always  a  predisposition  established.  The 
disease  may  disable  the  dentist  complete  in  the  pursuance  of  his 
practice.  The  writer  has  had  a  case  under  observation  for  sev- 
eral months  which,  at  times,  rendered  his  colleague  absolutely  un- 
fit to  attend  to  his  practice.  The  treatment  consists  primarily  in 
avoiding  contact  with  formalin.  Rubber  finger  stalls  should  be 
worn  and  as  a  therapeutic  suggestion,  Lassar's  paste,  containing 
10  per  cent  birch  tar,  may  be  tried  or  the  following  ointment  may 

be  applied : 

R     Tumenol  3  ijss   (10  Gm.) 

Amyli  5  ss   (15  Gm.) 

Zinci  oxidi  5  ss   (15  Gm.) 

Petrolati  5  j    (30  Gm.) 
M.  f.  ungt. 
Sig.:     Paint  on  the  affected  parts. 

Disinfection  of  Booms.  The  room  to  be  disinfected  should  have 
a  temperature  of  65°  F.  (18°  C.)  or  more,  and  the  air  present 
must  contain  at  least  75  per  cent  of  moisture.  This  humidity  can 
be  produced  by  placing  pans  of  steaming  hot  water  about  the 
room.  Drawers,  closet  doors,  etc.,  should  be  opened,  and  the 
furniture  moved  from  the  Avails.  Set  on  the  floor  in  the  middle 
of  the  room  a  large  tin  bucket,  in  Avhich  place  a  tin  can  of  suit- 
able capacit3\  Put  into  the  can  six  ounces  of  potassium  pci-man- 
ganate  crystals,  and  pour  over  them  one  pint  of  commercial  for- 
maldehyd  solution.^  These  quantities  are  sufficient  for  every 
thousand  cubic  feet  of  air  space.  The  operator  should  leave  the 
room  at  once,  as  large  quantities  of  formaldehyd  gas  are  imme- 
diately evolved.  The  room  must  be  closed  air  tight,  and  not 
opened  for  at  least  six  hours.  Furniture,  draperies,  carpets,  pic- 
tures, etc.,  are  not  damaged  by  this  method  of  disinfection.  After 
the  disinfection  is  completed,  the  formaldehyd  gas  can  be  neutral- 
ized by  ammonia,  so  as  to  render  the  room  fit  for  occupation.  This 
may  be  readily  accomplished  by  placing  in  a  suitable  vessel  two 

1  Recently  sodium  dicliromate,  10  ounces  (300  Gm.),  and  sulphuric  acid,  commercial, 
1  Vj  fluid  ounces  (45  C.c),  have  been  substituted  with  equally  good  results  for  potassium 
permanganate,  6  ounces  (180  Gm.). 


170 


PHARMACO-THERAPEUTICS 


pounds  of  freshly  burnt  lime,  seven  pints  of  boiling  water,  and 
three  pints  of  strong  ammonia  water.  After  one  hour's  exposure 
to  the  ammonia  vapors  the  room  should  be  well  aired. 

Therapeutics. — Formaldehyd  is  much  restricted  in  its  thera- 
peutic application  by  its  powerful  irritating  property,  its  pungent 
odor,  and  by  the  rapid  volatilization  of  the  gas.  To  remove  or 
neutralize  these  properties,  a  number  of  compounds  have  been 
produced  by  utilizing  the  peculiar  affinity  which  formaldehyd  has 
on  starch,  gelatin,  and  albumin  solutions.  The  resulting  products 
are  respectively  known  as  amyloform,   glutol,    and    formalbacid. 


'IIIIIIIIMIII^ 


Fig.  32. 
Formangaiiate  disinfector,  formanganate  solution  and  fornianganate   briquettes. 

These  compounds  have  been  used  to  some  extent  in  minor  surgery 
and  dermatology,  but  are  largely  abandoned  at  present.  It  is  also 
known  that  formaldehyd  is  readily  liberated  from  certain  organic 
compounds  in  the  genito-urinary  tract  when  taken  internally. 
Nascent  formaldehyd  forms  soluble  compounds  with  uric  acid. 
Since  this  fact  became  known  innumerable  compounds  have  been 
forced  on  the  market,  among  which  hexamethylenamin  (also  known 
as  urotropin,  formin,  saliformin,  and  cystogen),  tannopin,  tanno- 
form,  urasol,  formidin,  etc.,  are    the    most    prominent    members. 


ANTISEPTICS  171 

Thorald  Sollman  has  recently  shown  that  "of  all  the  products  ex- 
amined for  antiseptic  value,  hexamethylenamin  is  the  only  one 
which  offers  undoubted  advantages  over  the  other  antiseptics." 

As  an  antiseptic,  formaldehyd  has  gained  an  enviable  reputa- 
tion in  conservative  dentistry.  It  is  somewhat  difficult  to  state 
at  present  who  introduced  this  chemical  into  our  profession. 
While  we  find  some  references  relative  to  its  dental  use  as  early 
as  1894,^  the  earliest  important  communications  are  those  made  by 
Marion^  (1895),  Lepkowski^  (1895),  Schroder*  (1896),  Witzel" 
(1898),  B6nnecken«  (1898),  Prinz^  (1898),  etc.  They  are  now 
followed  in  rapid  succession  by  many  writers  here  and  abroad. 
On  account  of  its  strong  irritating  action,  formaldehyd  is  di- 
luted or  combined  with  many  other  agents — alcohol,  oil  of  gera- 
nium, cresol,  phenol,  etc. — and  has  been  principally  employed  ever 
since  in  mixtures  of  this  nature.  In  1899  Gysi*  introduced  a  mix- 
ture of  cresol  and  formalin  for  the  treatment  of  pulp  gangrene 
and  for  the  mummification  of  pulp  stumps  left  in  the  root  canals, 
but  it  remained  for  Buckley^  to  bring  this  combination  prominent- 
ly before  the  Fourth  International  Dental  Congress  in  1904. 

In  the  current  literature  on  the  treatment  of  infected  root  canals 
the  term  asepsis,  antisepsis,  and  sterility  are  frequently  employed 
in  a  rather  loose  manner,  which  may  lead  to  serious  misinterpre- 
tations. Asepsis  indicates  an  absence  of  pathogenic  bacteria ;  anti- 
sepsis means  inhibition  of  the  pathogenic  bacteria,  but  with  no 
interference  with  their  spores;  and  sterilization  implies  the  de- 
struction of  all  vegetative  organisms,  their  spores,  and  their  prod- 
ucts. An  incipiently  infected  root  canal  of  a  pulpless  tooth  in 
situ  may  be  rendered  aseptic  by  the  free  use  of  antiseptics,  but 
it  is  probably  impossible  to  completely  sterilize  infected  tooth 
structure. 

The  treatment  of  an  infected  root  canal  depends  on  chemie  and 
mechanical  measures.     The  mechanical  removal  of  the  putrescent 


^British  Dental  Journal,  April,  1894;  Cassidy:  Transact.  Am.  Dental  Assn.,  1894. 
'Marion:  I/'Odontologie,  January,  1895. 

'Lepkowski:  N'erhandlungen    der    Deutschen    Odontologischen    Gesselschaft,    \'ol.    VII, 
1896. 

*  Schroder:   Deutsche  Monatsschrift  fiir  Zahnlieilkunde,  June,  1896. 

"Witzel:   Deutsche  Monatsschrift  fiir  Zahnheilkunde,  December,   1898. 

•Bonnecken:    Osterreich-Ungarische    Vierteljahrsschrift    fiir    Zahnheilkunde,    January, 


U 


'Prinz:   Dental    Review,   October,    1898. 

*Gysi:   Schweizer  Vierteljahrsschrift  fiir  Zahnheilkunde,  No.   1,  1899. 

•Buckley:   Transactions  of  the  Fourteenth  International  Dental  Congress,  Vol.  II,  1905. 


172  PHARMACO-THERAPEUTICS 

pulp  tissue  is  the  foundation  of  the  successful  conservative  treat- 
ment of  the  tooth.  The  introduction  of  the  cresol-formalin  mix- 
ture for  the  purpose  of  therapeutically  treating  infected  root 
canals  places  this  procedure  on  a  rational  basis,  which,  on  account 
of  its  importance  deserves  to  be  discussed  in  detail. 

Decomposition  of  the  Tooth  Pulp  and  Its  Treatment  with 
Formaldehyd-Cresol.  The  human  tooth  pulp — that  is,  the  sound 
healthy  pulp — consists  of  connective  tissue,  nerves,  and  blood 
vessels.  It  is  generally  admitted  at  present  that  the  pulp  con- 
tains h'mph  spaces.  The  animal  tissues  are  essentially  composed 
of  cells,  and  the  constituents  of  the  cells  consist  of  protein,  lipoids, 
salts,  and  water.  Only  a  very  few  elements  enter  into  their  make- 
up— nitrogen,  oxygen,  carbon,  hydrogen,  sulphur,  and  very  little 
phosphorus  and  iron.  The  tissues  containing  nitrogen  are  referred 
to  as  nitrogenous  substances,  or  proteins,  while  nonnitrogenous 
substances  are  spoken  of  as  carbohydrates  and  fats.  The  normal 
pulp  tissue  is  composed  principally  of  protein  material,  and  so 
far  no  carbohydrates  or  free  fats  have  been  isolated  from  it.  The 
proteins  are  the  most  complex  bodies  known  to  chemistry ;  they 
are  usually  colloidal  in  their  nature,  and  are  composed  of  mole- 
cules that  differ  widely  in  their  weight  and  size.  The  average  pro- 
tein molecule  approximately  furnishes  the  following  constituents : 
Carbon,  51  to  55  per  cent;  oxygen,  20  to  24  per  cent;  nitrogen, 
15  to  17  per  cent;  hydrogen,  6.8  to  7.3  per  cent;  sulphur,  0.3  to 
0.5  per  cent,  and  very  small  quantities  of  phosphorus  and  iron. 
The  proteins  may  be  decomposed  bj'  acids,  alkalies,  superheated 
steam,  digestive  ferments,  and  bacteria.  In  the  decomposition  of 
the  pulp  we  are  principally  concerned  with  the  last  two  processes. 
Death  of  the  pulp— necrosis — is  the  progenitor  of  pulp  decompo- 
sition— gangrene. 

Whenever  health.y  tissue  becomes  irritated  by  mechanical,  physi- 
cal, or  chemic  (including  bacteria)  means  to  such  an  extent  as  to 
cause  intense  disordered  cell  nutrition,  death  of  the  cells  results. 
This  process  is  knoAvn  as  necrosis.  A  pulp  maj'  accidentally  die 
of  its  own  accord  through  any  of  the  above  causes,  or  it  is  artificial- 
ly killed  by  a  caustic,  usually  arsenic  trioxid.  In  general  path- 
ology we  recognize  four  distinct  forms  of  necrosis: 

1.  Coagulation  Necrosis.  This  form  of  necrosis  results  from 
the  coagulation  of  fluids  that  have  entered  into  or  are  present  in 
the   pulp,    and    th;it    contain    coagulable   substances — that    is,    tht- 


ANTISEP'l'lCS  173 

soluble  colloidal  material  is  transforined  into  insoluble  modifica- 
tions. The  change  of  fibrinogen  into  fibrin  is  an  important  factor 
in  this  procedure.  The  pulp  assumes  a  dry,  firm  appearance,  and 
is  usually  of  a  yellowish  color.  When  blood  enters  into  the  root 
canal  after  the  removal  of  a  coagulated  pulp,  it  usually  becomes 
quickly  clotted.  Coagulation  necrosis  may  be  caused  by  heat, 
phenol,  cori'osive  sublimate,  and  othei'  chemicals,  and  it  is  rathei' 
seldom  met  in  the  dead  dental  pulp. 

2.  Liquefaction  or  Colliquation  Necrosis.  This  occurs  princi- 
pally in  the  central  nervous  system.  The  nature  of  this  form  of 
necrosis  is  not  quite  clear,  and  probably  edematous  infiltration  and 
enzyme  action  have  much  to  do  with  it.  It  is  very  rarely  found 
in  the  dead  pulp.  Suppuration  should  not  be  confounded  with  it. 
It  is  principally  due  to  bacteria,  or  to  the  action  of  chemic  sub- 
stances (aseptic  suppuration). 

3.  Caseation  Necrosis.  This  is  a  coagulation  necrosis,  which 
resembles  an  emulsion  of  fat  and  water,  and  has  the  appearance 
of  cheese.  The  coagulum  is  made  up  of  protein  derivatives,  con- 
siderable quantities  of  fat  and  water,  etc.  Fatty  degeneration  of 
the  pulp  as  a  whole  is  rarely  met.  The  fat  globules  are  derived 
from  the  disintegration  of  cell  protoplasm,  which  contains  fat 
as  a  metabolic  constituent.  The  action  of  proteolytic  enzymes 
(trypsin)  is  probably  largely  responsible  for  these  changes. 
Caseation  is  frequently  found  in  pulp  decomposition. 

4.  Gangrene.  Gangrene  is  the  result  of  putrefactive  changes 
occurring  in  necrotic  tissues.  Two  forms  of  gangrene  are  usually 
recognized  in  general  pathology — moist  and  dry  gangrene.  Moist 
gangrene  depends  on  the  presence  of  water,  while  the  absence  of 
water  denotes  dry  gangrene  or  mummification.  In  dry  gangrene 
nearly  all  further  changes  cease,  Avhile  in  the  moist  form  the  auto- 
lytic  changes  continue.  A  totally  gangrenous  pulp  presents  a 
mass  of  debris  in  which  lime  concretions,  fat  droplets,  crystals  of 
fatty  acids,  crystals  of  hematoidin,  crystals  of  triple  phosphates, 
numerous  bacteria,  and  various  pigments  are  the  only  distinguish- 
able elements.  The  fat  droplets  are  partially  produced  by  fatty 
degeneration  of  the  myelin  sheets  of  the  nerve  fibers  and  partially 
by  disintegration  of  the  cell  protoplasm  and  dead  bacteria,  which 
apparently  contain  fat  as  metabolic  constituents  in  the  form  of 
lipoids.  In  the  great  majority  of  cases  of  pulp  disintegration  pro- 
gressive moist   gangrene   is   predominating.     In   clinical   practice 


174  PHARMACO-THERAPEUTICS 

complete  moist  gangrene  is  not  always  found,  and  a  pulp  may  be 
partially  or  totally  gangrenous.  In  partial  gangrene  one  part  of 
the  pulp  may  be  totally  putrescent,  while  the  other  part  may  be 
still  in  a  state  of  severe  inflammation.  A  fairly  distinct  line  of 
demarcation  may  be  observed  between  the  dead  and  the  inflamed 
part  of  the  pulp.  Through  necrobiotic  changes  the  entire  pulp 
will  finally  become  totally  gangrenous. 

When  dead  protein  material  is  subjected  to  the  action  of  bacte- 
ria and  ferments,  the  process  is  known  as  putrefaction.  Putrefac- 
tion in  its  early  stages  is  principally  a  process  of  hydrolysis  and 
oxidation,  and  resembles  closely  tryptic  digestion — that  is,  certain 
ferments,  enzymes,  and  products  of  bacterial  activity  are  concerned 
in  the  cleavage  action  of  the  protein  molecule,  a  process  which  is 
closely  allied  to  the  changes  occurring  in  the  intestinal  tract.  The 
preliminary  action  of  proteolytic  enzymes  on  the  dead  protein 
molecule  results  in  the  formation  of  albumoses  and  peptons.  The 
further  decomposition  of  the  peptons  is  productive  of  various 
amino  acids — as  fatty  and  aromatic  acids — in  which  one  of  the 
hydrogen  atoms  has  been  replaced  by  a  basic  ammonia  radical.  It 
is  claimed  by  Czapek  and  Emmerling  that  these  amino  acids  fur- 
nish excellent  nutrition  for  bacteria.  The  amino  acids  are  further 
decomposed  by  the  elimination  of  ammonia  and  by  the  splitting  off 
of  carbon  dioxid.  In  the  ammonia  elimination  the  end-products 
are  found  to  consist  of  the  free  fatty  acids  corresponding  to  the 
amino  acids  from  which  they  are  derived — as  acetic,  propionic, 
butyric,  valerianic,  caproic,  and  a-amino-valerianic  acid — and  of 
the  aromatic  acids — as  phenyl-propionic,  hydro-p-cumaric,  skatol- 
acetie,  and  succinic  acid.  Sulphur  is  set  free  during  the  break- 
ing down  of  the  protein  substances;  it  partially  unites  with  free 
hydrogen  to  form  hydrogen  sulphid,  and  partially  with  free  CN 
groups  to  form  various  sulpho-cyanids  of  a  less  toxic  character. 
The  further  oxidation  of  the  various  fatty  acids  results  in  the 
formation  of  many  para-oxy  acid  compounds — as  paracresol, 
phenol,  etc.  In  the  course  of  their  decomposition  the  aromatic 
products  furnish  indol  and  skatol ;  indol  finally  combines  with 
free  sulphuric  acid  and  forms  indican.  The  latter  substance  fur- 
nishes an  important  diagnostic  indicator  of  the  progress  of  putre- 
faction. The  aromatic  and  fatty  acids,  but  especially  skatol  and 
indol,  are  largely  responsible  for  the  vile,  fetid  odor  which  accom- 
panies the  putrefaction  of  protein  material.     The  final  end-prod- 


ANTISEPTICS  175 

ucts  are  water,  ammonia,  hydrogen,  hygrogen  sulphid,  and  carbon 
dioxid.  This  last  stage  of  complete  decomposition  is  rarely 
reached  in  the  putrefaction  of  the  pulp  tissue.  The  reaction  of 
the  putrescent  pulp  is  probably  always  alkaline,  and  the  necessary 
carbohydrates  which  would  furnish  the  acids  by  fermentation  are 
absent.  The  acids  that  are  formed  during  the  decomposition  of 
protein  matter  are  readily  neutralized  by  the  many  basic  materials 
that  are  created  simultaneously  with  the  acids.  It  may  be  ob- 
served, however,  that  in  the  union  of  two  amino  acids  an  acid  radi- 
cal and  a  basic  radical  are  liberated,  which,  under  certain  con- 
ditions, give  rise  to  an  amphoteric  reaction. 

The  bacterial  phase  of  pulp  decomposition  is  of  even  greater 
clinical  significance  than  its  chemistry.  Hand  in  hand  with  the 
progress  of  chemie  decomposition,  the  bacteria  that  are  present 
in  the  pulp  tissue  give  rise  to  many  substances — as  ptomains,  tox- 
ins, endotoxins,  and  bacterial  proteins.  Moist  gangrene  results 
from  the  dual  action  of  the  proteolytic  enzymes  and  putrefactive 
organisms.  Mayrhofer^  furnishes  the  following  statistics  concern- 
ing the  presence  of  micro-organisms  in  dead  pulp  tissue. 

Number  of  times 

Organisms  found.  found. 

Streptococci    70 

Streptococci  and  rods 44 

Streptococci   and   staphylococci 14 

Streptococci,  staphylococci,  and  rods 10 

Streptococci  and  yeast  cells 5 

Streptococci,  rods,  and  yeast  cells 3 

Staphylococci   3 

Staphylococci  and  rods 1 

Rods     2 

Concerning  the  presence  of  these  various  micro-organisms  in 
open  and  closed  putrescent  root  canals,  Mayrhofer  obtained  the 
following  data : 

Number  of  times  Number  of  times 

Organisms  found.                                found  in  53  cases  of  found  in  51  case's  of 

open  root  canals.  closed  root  canals. 

Streptococci    27  31 

Staphylococci  and  rods 18  6 

Streptococci   and   staphylococci 3  1 

Streptococci,  staphylococci,  and  rods ....            1  5 

Streptococci  and  yeast  cells 1 

Staphylococci   1  2 

Staphylococci  and  rods 1 

Rods  1  6 

*  Mayrhofer:   Principien  der  Pulpagangran,  1909. 


176  PHARMACO-THERAPEUTICS 

The  influence  of  bacteria,  per  se,  is  of  little  importance  as  far  as 
pathogenic  disturbances  are  concerned,  and  the  harm  that  is 
caused  by  the  presence  of  these  organisms  is  due  to  the  many 
chemic  products  that  result  in  one  way  or  another  from  their 
metabolic  prosesses.  The  many  offensive  products  that  accom- 
pany putrefactive  changes  are  attributed  to  anaerobic  conditions, 
while  in  the  presence  of  oxygen  usually  less  ill-smelling  com- 
pounds are  formed.  Some  observeis  claim  that  onlj^  strictly  anae- 
robic bacteria  are  concerned  in  the  putrefaction  of  proteins.  The 
streptococci  and  the  staphylococci  are  both  aerobic,  and  only  op- 
tionally anaerobic  organisms.  The  presence  of  the  malodorous 
compounds  is  readily  perceived  h\  entering  into  a  closed  root  canal 
containing  a  putrescent  pulp. 

The  poisonous  chemic  products  of  bacteria  may,  according  to 
Wells,  be  conveniently  divided  into  ptomains,  toxins,  endotoxins, 
and  bacterial  proteins.  The  ptomains — soluble  basic  nitrogenous 
substances  resembling  vegetable  alkaloids.  For  some  time  past 
it  was  believed  that  ptomains  were  the  cause  of  infectious  disease, 
but  it  was  soon  found  that  they  could  be  removed  from  cultures  of 
pathogenic  bacteria  without  destroying  the  poisonous  nature  of 
the  latter.  At  present  the  chemistr}^  of  bacterial  intoxication  is 
more  clearly  worked  out,  and,  as  a  consequence,  ptomains  are  of 
much  less  interest  than  they  were  twenty  years  ago.  In  decom- 
posing protein  material  quite  a  large  number  of  ptomains  are  more 
or  less  present  as  a  result  of  the  cleavage  action  of  enzjnnes  and 
other  hydrol^'tic  factors.  Cadaverine,  putrescine,  sepsine,  mus- 
carine, leucine,  tyrosine,  neuridine,  etc.,  are  some  of  the  more 
important  representatives  of  this  interesting  group.  Ptomains  do 
not  act  as  specific  poisons,  but  many  produce  diseases  when  taken 
into  the  body  Avith  food  in  which  they  have  been  produced  by  bac- 
terial activity.  It  is  claimed  that  pathogenic  bacteria  present  in 
living  tissue  can  not  produce  sufficient  ptomains  to  seriously  affect 
the  health  of  the  individual.  Moist  gangrene  of  the  pulp  is  a 
ready  source  of  ptomain  formation. 

Certain  pathogenic  bacteria  produce  definite  sj'nthetic  poison- 
ous substances  of  a  specific  nature — the  toxins.  Toxins  are  the 
secretions  of  cells,  and  are  readily  taken  up  by  the  surrounding 
tissue.  The  intense  poisonous  nature  of  these  toxins  is  responsible 
for  the  chief  symptoms  which  we  recognize  in  infectious  diseases. 
The    bacillus    of    diphtheria    and    tetanus    and    the    specific    pus 


ANTISEPTICS  177 

bacilli  are  known  to  secrete  typical  toxins.  These  toxins  are  al- 
ways of  the  same  poisonous  nature,  no  matter  how  or  where  they 
are  produced,  while  the  ptomains  vary  with  the  nature  of  the  sub- 
stances from  which  they  are  produced.  Toxins  are  very  labile 
substances,  and  they  are  readily  destroyed  by  heat,  direct  sun 
light,  and  oxygen.  Antibodies  or  antitoxins  can  be  prepared 
against  toxins,  but  not  against  ptomains.  As  very  few  bacilli  arc 
known  that  produce  specific  toxins,  it  is  plain  why  so  few  true 
antitoxins  have  been  artificially  prepared. 

Again,  bacteria  may  produce  poisons  within  their  own  cell 
bodies;  they  are  not  usually  secreted  by  the  cells,  but  are  also 
specific  in  their  poisonous  nature.  These  bodies  are  known  as 
endotoxins.  As  yet  no  antitoxins  have  been  prepared  against 
endotoxins,  and,  as  most  bacterial  diseases  are  caused  by  endotox- 
ins, the  preparation  of  sera  has  been  greatly  retarded,  and  con- 
sequently immunization  against  many  infectious  diseases  is  ap- 
parently impossible.  Furthermore,  bacteria  contain  poisonous  ma- 
terials which  form  an  integral  part  of  their  protein  constituents. 
These  poisonous  materials  are  not  soluble,  and  apparently  do  not 
produce  diseased  conditions.  The  bacterial  substance  itself  may, 
however,  produce  inflammation  and  pus,  or  even  necrosis,  when 
injected  into  living  tissues.  These  substances  are  called  bacterial 
proteins. 

The  formaldehyd-cresol  mixture  which  is  generally  employed  at 
present  consists  of  equal  parts  of  formaldehyd  and  cresol,  and  for 
the  sake  of  convenience,  is  termed  formocresol.  If  the  formalde- 
hyd solution  is  diluted  with  water  prior  to  the  addition  of  cresol, 
the  latter  will  separate  from  the  mixture.  Formaldehyd  develops 
its  strongest  antiseptic  power  Avhen  applied  in  vapor  form  on 
moist  surfaces,  but  on  dry  material  it  is  almost  without  action.  '  At 
ordinary  temperature  it  gives  up  vapors  of  formaldehyd  and  at 
body  temperature  this  vaporization  is  increased.  The  vapors  of 
formaldehj'd  are  very  penetrating,  a  factor  that  is  of  prime  im- 
portance in  the  treatment  of  a  putrescent  canal.  As  a  general  de- 
odorant, formaldehyd  acts  rather  weakly  unless  it  directly  com- 
bines with  odoriferous  substances  to  form  new  compounds — as  am- 
monia, hydrogen  sulphid,  etc.  Cresol,  commercially  known  as 
tricresol,  is  a  mixture  of  metacresol,  oi'thocresol,  and  paracresol : 
its  most  active  component  is  metacresol.  Cresol  is  about  two  and 
a  half  times  as  active  as  phenol  in  antiseptic  action,  and  about  four 


178  PHARMACO-THERAPEU'nCS 

times  less  poisonous  to  the  animal  organism.  Cresol  is  a  powerful- 
ly deodorizing  medium,  and  acts  on  wound  surfaces,  like  all 
antiseptics  of  the  benzol  ring,  as  a  slight  anesthetic.  Compounds 
of  cresol,  or  of  phenol,  and  formaldehyd  have  been  recentlj^  pre- 
pared by  manufacturing  chemists  (decillan,  phenyform),  and  are 
used  at  present  with  apparently  good  success  in  the  treatment  of 
inoperable  carcinoma  of  the  uterus,  etc.  (Torggler.)  Regarding 
the  action  of  formaldehyd  on  putrescent  pulp  tissue,  it  should  be 
remembered  that  its  combination  with  the  gases  resulting  from 
the  decomposition  of  the  pulp  is  of  less  importance  to  the  future 
welfare  of  the  tooth  than  its  destructive  action  on  bacteria  and 
their  products.  As  stated  above,  ammonia,  hydrogen  sulphid,  and 
carbon  dioxid  are  end-products  of  putrefaction,  and  consequently 
are  not  always  met  in  every  case  of  death  of  the  pulp  that  comes 
to  us  for  treatment.  These  gases  are  absent  in  putrescent  pulps 
that  are  found  in  open  root  canals.  Buckley  states  that  cresol  acts 
chemically  on  the  fatty  compounds,  thereby  disposing  advantage- 
ously of  these  substances  by  saponifying  the  fats,  which  results  in 
a  compound  somewhat  similar  to  lysol.  This  statement,  however, 
is  incorrect.  Fats  are  insoluble  in  cresol  or  formaldehyd,  or  its 
combinations,  and  saponification  can  result  only  through  the 
presence  of  an  alkali.^  Furthermore,  cresol  acts  not  merely 
as  a  diluent  of  the  formaldehyd  solution,  and  its  very  important 
function  in  the  treatment  of  putrescent  pulp  is  readily  understood 
when  we  observe  its  chemic  action  on  the  products  of  protein  de- 
composition. Cresol  is  the  solvent  of  the  vile-smelling  fatty  acids^ 
— indol,  skatol,  and  other  products  of  enzyme  action  and  bacterial 
metabolism.  The  very  fact  that  paracresol  and  other  similar  com- 
pounds are  some  of  the  end-products  of  protein  decomposition 
seems  to  point  to  the  possibility  that  nature  herself  intended  to  ar- 
rest the  process  of  putrefaction.  The  destruction  or  removal  of 
fats  is  of  less  importance  from  a  pathologic  point  of  view,  and  is 
readily  accomplished  by  mechanical  or  chemic  means — as  sodium 
dioxid,  potassium  hydroxid,  kalium-natrium  alloy,  etc.  The  slight 
coagulating  properties  of  cresol  have  no  significance  in  the  pres- 
ence of  formaldehyd,  as  the  latter  readily  penetrates  through  eoagu- 


*  Lysol  is  a  compound  that  is  closely  related  to  the  compound  solution  of  cresol  of  the 
United  States  Pharmacopeia — a  saponified  mixture  of  cresol  and  linseed  oil — and  conse- 
quently no  solution  of  fats  or  formation  of  lysol-Iike  compounds  result  from  the  action  of 
cresol  alone  or  when  assisted  by  alcohol,  as  has  been  stated. 

*  Willieer:   Deutsche  Zahnarztliche  Wochenschrift,   1907,  p.   553. 


ANTISEPTICS  179 

lated  albumin.  Basing  our  hypothesis  on  the  ehemic  reactions  that 
occur  when  formoeresol  is  brought  in  contact  with  putrescent  pulp 
tissue  the  following  conclusions  are  obviously  deducible :  Formal- 
dehyd  destroys  bacteria  and  their  products,  and  combines  with  cer- 
tain gases  to  form  inert  soluble  compounds ;  cresol  readily  dissolves 
fatty  acids  and  destroys  ptomains,  toxins,  and  other  bacterial 
products,  and  modifies  tlie  caustic  action  of  formaldehyd.  Both 
chemicals  are  strong  deodorizers,  and  their  combined  action  in- 
creases the  total  power  of  their  individual  antiseptic  activity.  Ac- 
cording to  modern  pharmacologic  conception,  a  mixture  of  an  anti- 
septic of  the  benzol  series  with  an  antiseptic  of  another  kind  is  still 
more  efficient  than  the  corresponding  proportion  of  either  alone. 
(Cushny.) 

In  the  routine  practice  of  treating  putrescent  root  canals  we  de- 
pend almost  solely  on  the  absence  of  foul  odors  and  on  the  discolora- 
tion of  the  cotton  dressing  as  the  diagnostic  signs  for  a  probably 
established  asepsis.  The  true  criterion  for  asepsis  is,  however, 
found  only  in  a  bacteriologic  test.  Asepsis  of  an  infected  root 
canal  can  be  temporarily  established  by  applying  ehemic  and 
mechanical  measures,  but  complete  sterilization  of  infected  dentin 
in  a  tooth  in  situ  is  extremely  questionable.  According  to  our  pres- 
ent method  of  applying  antiseptics,  we  can  never  reach  the  in- 
fected contents  of  the  dentinal  tubules,  the  deltoid  foramina,  or 
the  many  nidi  of  the  ramified  root  canal.  Miller  has  emphasized 
the  fact  that  in  the  treatment  of  putrescent  pulps  we  do  not  have 
to  be  alarmed  about  the  presence  of  bacteria  in  the  dentinal  tubules, 
as  exhausting  the  pabulum  keeps  the  micro-organisms  in  check. 
Recent  experimental  work  conducted  by  Mayrhofer,  Baumgartner, 
and  others  verifies  the  statement  that  bacteria  and  their  spores  are 
always  present  in  the  dentin  of  such  teeth  as  have  been,  at  one 
time  or  another,  under  antiseptic  treatment.  The  lumen  of  the 
dentinal  tubules  varies  from  1.3  to  3.2  /x,  and  the  average  size  of 
a  streptococcus  is  probably  not  much  larger  than  1  fi;  hence  the 
ready  advance  of  the  latter  into  the  tubules.  Even  such  powerful 
disinfectants  as  potassium  hydroxid  ( Hatty  asy),  formoeresol 
(Mayrhofer),  or  heat  (Baumgartner)  will  not  sterilize  infected 
tooth  substances.  Filling  of  all  the  accessible  parts  of  a  root  canal 
with  a  nonputrefying  material  produces  unfavorable  conditions 
for  the  growth  of  bacteria ;  if  the  root  filling  itself  is  a  persistent 
antiseptic  and  mummifying  agent,  the  chances  are  more  in  favor 


180  PHARMACO-THERAPEUTICS 

of  the  permanency  of  our  efforts.  .  At  any  time,  however,  when 
the  vitality  of  the  individual  becomes  lowered  and  the  natural 
bodies  of  defense  present  in  the  circulation  are  lessened,  the  filled 
tooth  offers  a  place  of  minor  resistance  to  the  present  restive  forms 
of  micro-organisms,  and  periapical  disturbances  follow^  with  the 
possibility  of  abscess  formation. 

As  far  as  clinical  practice  is  concerned,  the  diagnosis  of  the  con- 
ditions of  a  dead  pulp  is  of  little  importance  as  regards  the  ex- 
act differentiation  between  the  various  forms  of  necrosis  and  gan- 
grene. The  routine  treatment  of  a  dead  pulp  is  practically  the 
same,  except  in  those  cases  where  only  a  partial  necrosis  of  the 
pulp  is  present.  To  simplify  matters,  we  will  refer  to  a  pulp 
that  has  died  by  accident  as  a  gangrenous  pulp,  no  matter  in  what 
state  of  decomposition  the  pulp  tissue  may  be  found.  The  treat- 
ment of  the  sequelsB  of  the  various  forms  of  gangrene — perice- 
mentitis, alveolar  abscess,  etc. — has  no  bearing  on  our  present  con- 


Fig.  33. 

Aseptic  absorbent  paper  points. 

sideration.  The  treatment  of  pulp  gangrene  necessarily  divides 
itself  into  three  definite  phases: 

The  antiseptic  treatment. 

The  chemic  treatment. 

The  mechanical  treatment. 

To  open  into  a  tooth  with  a  putrescent  pulp  does  not  i-equire 
the  adjustment  of  the  rubber  dam,  and  its  presence  has  no  influ- 
ence on  existing  conditions.  Suitable  napkins,  cotton  rolls,  etc., 
properly  applied,  save  much  valuable  time  and  unnecessary  an- 
noyance to  the  patient.  The  pulp  chamber  is  opened  as  wide  as 
possible,  washed  out,  and  as  much  as  possible  of  the  moisture  of 
the  canal  is  removed  with  aseptic  paper  canal  points.  A  small 
pledget  of  cotton  saturated  with  formocresol  is  now  placed  in  in- 
timate contact  with  the  gangrenous  mass  and  sealed  into  the  canal 
by  flowing  a  thin  cement  over  the  opening  without  pressure.  If 
the  pericementum  is  involved,  it  is  better  practice  not  to  seal  the 


ANTISEPTICS  181 

tooth  at  the  first  consultation.  The  patient  should  return  in  two 
or  three  days,  when  the  tooth  is  again  opened,  and  an  effort 
is  made  to  carefully  remove  the  contents  of  the  canal  with  suit- 
able broaches.  Dipping  the  broach  into  a  suitable  antiseptic  at  fre- 
quent intervals  and  wiping  the  gangrenous  material  on  a  piece  of 
cotton  cloth  will  be  of  great  assistance  in  accomplishing  the  pur- 
pose. Extreme  care  should  be  exercised  not  to  force  the  broach 
through  the  foramen,  and  all  unnecessary  manipulations  in  the 
canal  should  be  avoided.  The  canal  may  now  be  washed  out  with 
hot  water,  alcohol,  etc.,  and  a  loose  dressing,  carrying  formocresol, 
is  placed  in  the  canal.  Small  pieces  of  waxed  floss  silk  or  very  thin 
catgut  (the  finest  violin  string),  which  are  permanently  kept  in 
the  above  mixture,  are  of  great  assistance  in  carrying  the  medica- 
ment to  place.  The  second  dressing  should  remain  undisturbed 
for  a  few  days.  The  condition  of  the  canal  at  the  next  sitting 
will  indicate  further  procedure.  If  a  part  of  the  pulp  tissue 
should  still  possess  Adtality,  the  proper  treatment  depends  on  the 
stage  of  inflammation.  Anesthetization  or  devitalization  of  the 
pulp  stump  may  be  indicated.  If  the  conditions  mentioned  are 
present  in  a  multirooted  tooth,  a  pledget  of  cotton  saturated  with 
formocresol  is  placed  over  the  canal  containing  the  putrescent 
pulp  and  sealed  with  cement,  and  the  other  pulp  stumps  are 
treated  as  previously  outlined.  As  a  final  cleansing  process,  the 
use  of  sodium  dioxid,  as  suggested  by  Kirk,  in  conjunction  with 
50  per  cent  sulphuric  or  10  per  cent  hydrochloric  acid,  or  undiluted 
nitro-hydrochloric  acid  is  now  indicated.  Either  of  the  acids  is 
pumped  into  the  canal,  and  then  neutralized  with  sodium  dioxid, 
carried  on  a  broach  moistened  with  alcohol  or  chloroform,  accord- 
ing to  the  following  equations: 

H2SO,+Na,Oo=Na,SO,-fH,02, 
or  2HCl+Na262=2NaCl+H202. 
or  2HN03+Na20,=2NaN03+H20o  and 
2HCl+Na262=2NaCl+H202  and 
H202+2HCl=2H,0-fClo. 
The  evolution  of  nascent  oxygen  is  an  important  factor  as  it  will 
assist  in  preserving  the  natural  color  of    the    tooth.      Hydrated 
chloral  in  concentrated  aqueous  solution,  with  the  addition  of  10 
per  cent  hydrochloric  acid,  has  been  recently  advocated  by  Baum- 
gartner  for  the  final  cleansing  of  an  infected  root  canal,  and  is 
apparently  very  useful  for  this  purpose.    After  the  final  treatment 


182  PKARMACO-THERAPEUTICS 

the  canal  should  be  dried,  and  no  time  should  be  lost  in  filling  it 
with  the  proper  material  indicated  for  the  purpose. 
Alcohol;  Alcohol,  U.  S.  P.;  Spiritus  Rectificatus,  B.  P.;  Re- 
fined Spirit;  Ethyl  Alcohol;    Grain    Alcohol;    Spirit    of 
Wine  ;  Alcool,  F.  ;  Weingeist,  G. 

Alcohol  contains  92  per  cent  by  volume  of  ethyl  alcohol, 
C2H5OH.  The  preparation  of  the  British  Pharmacopeia  contains 
90  per  cent  of  volume.  It  is  a  transparent,  colorless,  mobile,  and 
volatile  fluid,  having  an  agreeable  odor  and  taste.  An  absolute 
alcohol  containing  not  more  than  1  per  cent  by  weight  of  water 
and  the  diluted  alcohol  containing  41  per  cent  by  weight  of  ethyl 
alcohol  are  also  official. 

Alcohol,  Metliyllic;  CH3OH.  Wood  alcohol,  wood  spirit,  or 
naphtha.  A  product  of  destructive  distillation  of  wood.  It  is  a 
colorless,  clear  liquid,  having  a  characteristic  odor  and  taste.  It 
is  miscible  in  all  proportions  with  water,  alcohol,  ether,  etc.,  and 
boils  at  150°  F.  (65°  C).  Wood  alcohol  is  rarely  employed  for 
medicinal  purposes,  and  its  use  as  a  substitute  for  grain  alcohol 
is  prohibited.  Taken  internally,  or  even  inhaling  its  vapors, 
causes  poisonous  disturbances,  usually  resulting  in  blindness,  etc. 
Ethyl  alcohol  possesses  limited  antiseptic  power  and  precipitates 
albumin  when  applied  to  solutions  containing  at  least  65  per  cent 
or  more  of  pure  alcohol.  It  possesses  great  affinity  for  water,  and 
absorbs  it  freely  from  the  living  tissue  cell,  thereby  acting  as  a 
mild  caustic.  The  mucous  linings  of  the  mouth  and  stomach  of 
man,  being  more  or  less  continuously  abused,  have  acquired  a 
higher  resistance  to  the  action  of  alcohol,  and  are  apparently  not 
much  damaged  by  alcoholic  solutions  as  high  as  70  per  cent.  As 
an  abortive  treatment,  alcohol  indirectly  possesses  a  beneficial  in- 
fluence on  the  early  stages  of  abscess  formation.  When  applied  in 
the  form  of  an  alcohol  pack  or  bandage,  it  irritates  the  deeper 
structures,  thereby  producing  congestive  hyperemia,  which,  ac- 
cording to  Bier,  causes  an  increased  bacteriolytic  action  of  the 
blood — that  is,  the  increased  number  of  leucocytes  (phagocytes) 
and  the  proteoh'tic  action  of  the  blood  plasma  act  as  antiseptics 
and  absorbing  agents. 

The  antiseptic  action  of  alcohol  is  most  pronounced  when  ap- 
plied in  dilutions  of  70  to  80  per  cent.  Absolute  alcohol  possesses 
only  slight  antiseptic  power,  which  is  probably  due  to  the  rapid 
coagulation  of  albumin  of  the  cell  wall,  which  prevents  the  further 


ANTISEPTICS  183 

penetration  of  alcohol  through  this  dense  coagulated  layer.  It  is 
also  of  importance  to  remember  that  water-soluble  antiseptics  lose 
much  of  their  power  when  dissolved  in  or  mixed  with  alcohol, 
while  certain  other  antiseptics — as  phenol,  lysol,  and  thymol — act 
more  powerfully  when  dissolved  in  50  per  cent  alcohol  than  when 
an  equal  quantity  is  dissolved  only  in  water.  Solutions  of  phenol 
in  concentrated  alcohol  or  in  fatty  oils  are  comparatively  worth- 
less. The  bactericidal  action  of  alcohol  is  always  materially  in- 
creased when  applied  to  moist  surfaces.  A  70  per  cent  alcohol 
solution  in  water  will  be  about  equivalent  in  its  efficiency  to  a  3 
per  cent  phenol  solution  in  water.  Absolute  alcohol  in  connection 
with  the  warm  air  blast  is  effectively  employed  as  a  dehydrating 
agent  of  decalcified  dentin. 

FORMOCRESOL. 

Cresol 

Solut.  formaldehyd  aa  3  i  (4  C.c.) 

M.  f.  solut. 

Root  Canal  Filling  Material. 

POWDER. 

Thymol    5  parts. 

Exsiccated  alum    10  parts. 

Kaolin   25  parts. 

LIQUID. 

Solution   of   formaldehyd 1  part. 

Cresol 2  parts. 

Alcohol    3  parts. 

Chloro-Percha  and  Formalin  Root  Filling. 

Gutta-percha  base  plate 10  parts. 

Chloroform   25  parts. 

Eucalyptol 15  parts. 

Thymol    2  parts. 

Paraform    1  part. 

Dissolve  the  gutta-percha  in  the  chloroform.  Dissolve  the  thy- 
mol in  the  eucalyptol,  add  the  finely  powdered  paraform  and 
shake  vpell.  Mix  the  two  solutions,  and  keep  the  open  bottle  in 
a  warm  place  until  the  chloroform  has  evaporated. 


184  pharmaco-therai'eutics 

Pulp  Mummifying  Paste. 

Paraf  orm     1  part. 

Thymol    1  part. 

Zinc  oxid    2  parts. 

Glycerin enough  to  make  a  stiff  paste. 

Scheuer's  Rootfilling  Paste. 

Zinc   oxid    8  parts. 

Zinc   sulphate,   deliydrated 2  parts. 

Cresol     3  parts. 

Formaldehyd   solution    1  part. 

Eugenol     1  part. 

Glycerin enougli  to  make  a  stiff  paste. 

Essential  Oils,  their  Derivatives,  and  their  Synthetic  Substitutes. 

Essential,  ethereal,  volatile,  oi-  distilled  oils,  as  tliey  are  vari- 
ously termed,  are  usually  derived  by  distillation,  sometimes  by 
pressure,  or  by  maceration  (known  as  enfleui'age),  from  plants. 
The  odor  of  the  plant  is  primarily  due  to  the  presence  of  these 
oils.  The  oils  are  obtained  from  the  fruit,  the  flowering  part,  the 
bark,  or  from  the  entire  plant.  Occasionally  a  plant  may  produce 
two  different  oils,  like  the  juniper  tree,  or  even  three  different 
oils,  like  the  orange  tree,  in  its  various  parts.  The  eryptogamic 
plants  rarely  produce  essential  oils,  the  great  bulk  being  obtained 
from  the  phanerogams  of  which  the  following  families  are  typical 
representatives:  Birch,  ginger,  laurel,  lily,  myrtle,  mustard,  orange, 
parsley,  pine,  rue,  sunflower,  etc.  The  amount  of  oil  obtained  from 
the  various  plants  differs  widely,  and  may  range  from  0.1  to  20 
per  cent,  but  most  plants  produce  only  small  quantities. 

The  oils  are  usually  clear,  colorless,  sparkling  fluids,  which, 
by  exposure,  age,  or  the  presence  of  some  foreign  matter,  change 
to  3'ellow,  brown,  red  or  green.  Some  few  oils  possess  a  distinc- 
tive color — as,  the  oil  of  wormwood  is  dark  brown  (becoming  green 
or  bluish-green  with  age),  and  the  oil  of  chamomile  exhibits  a  pale 
blue  color.  The  stills  or  original  metallic  containers  maj^  impart 
a  distinctive  color  to  the  oils — as,  the  green  color  of  the  oil  of 
cajuput  may  be  traced  to  the  copper  stills,  or  the  copper  canisters 
in  which  the  oil  is  shipped. 

Essential  oils  ai-e  soluble  in  alcohol,  ether,  chloroform,  fatty  oils, 
etc.      They    are    easily    vaporized    without    decomposition,    but 


ANTISEPTICS  185 

readily  decompose  with  age  and  by  absorbing  oxygen ;  they  become 
darker  in  color,  and  thick  and  viscid,  depositing  resinous  precipi- 
tates. Agitated  with  water,  they  form  a  milky  mixture,  from 
which  the  oils  soon  separate,  imparting  their  odor  and  taste  to  the 
water.  Essential  oils  possess  a  strong  odor  and  taste,  and  are  used 
to  a  large  extent  in  perfumery  and  medicine  as  flavoring  agents. 
According  to  their  medicinal  properties,  they  are  classed  as 
diuretics,  expectoi-ants,  stomachics,  and  purgatives,  while  dentistry 
chiefly  relies  on  their  antiseptic,  obtunding,  and  stimulating  qual- 
ities. 

The  volatile  oils  do  not  belong  to  a  definite  chemic  group,  and 
are  consequently  extremely  difiicult  to  classify.  Most  of  the  oils 
are  composed  of  hydrocarbons,  represented  by  various  modifica- 
tions of  the  general  formula  known  as  terpcnes,  'Cr.Hs-n ;  or  com- 
posed of  oxygenated  aromatic  bodies,  as  alcohols  of  the  fatty 
series,  aldehyds,  acids,  kctons,  phenols,  esters,  etc. ;  or  they  may 
represent  a  mixtui-e  of  the  terpcnes  with  one  or  more  of  the  other 
bodies.^  The  terpenes  do  not  necessarily  carry  the  odorous  prin- 
ciple of  the  oils,  as  was  formerly  supposed ;  by  fractional  distilla- 
tion the  terpenes  may  be  removed  entirely,  and  the  oils  are 
thus  very  highly  concentrated.  Recently  organic  chemistry  has 
succeeded  in  producing  by  synthesis  quite  a  number  of  these  odor- 
iferous principles — as  methyl  salicylate,  geraniol,  artificial  oil  of 
roses,  heliotropin,  cumarin,  etc.  Halogen  derivatives  have  thus 
far  not  been  isolated  from  essential  oils.  Certain  oils  deposit  on 
standing,  or  when  exposed  to  low^er  temperature,  a  solid  crystalline 
substance  known  as  stearopten  or  camphen,  while  the  remaining 
fluid  is  termed  eleopten.-  A  few  oils  contain  nitrogenous  bodies 
in  the  form  of  cyanogen  compounds  (oil  of  bitter  almonds)  and 
of  sulphur  compounds  (volatile  oil  of  mustard).  Volatile  oils  dif- 
fer from  fixed  or  fatty  oils  in  so  far  as  they  do  not  form  glycerites 
(soap)  when  treated  with  alkalies;  they  do  not  decompose  by 
heat,  and  their  stain  on  paper  is  readily  volatilized. 

The  essential  oils  differ  very  widely  in  their  antiseptic  power. 
The  latter  depends  largely  on  their  volatility,  which,  according 
to  Cushny,  "enables  them  to  penetrate  readily  into  protoplasm, 
and  lessens  its  vitality  by  acting  as  foreign  bodies  (molecular  irri- 
tants) ;  in  addition,  they  are  nearly  related  to  the  benzol  series, 


'  Parry:  Chemistry  of  Essential  Oils  and  Perfumery,   1894. 
'  Powers:   Essential  Oils  and  Organic  Chemic  Preparations,  189^ 


186  PHARMACO-THERAPEUTICS 

the  members  of  which  are  all  antiseptics  and  protoplasm  poison." 
They  also  possess  anesthetic  properties.  When  applied  to  the 
skin  or  mucous  membrane,  the  volatile  oils  act  as  strong  irritants. 
This  irritating  property  of  the  oils  results  most  likely  from  the 
presence  of  the  terpenes,  which,  like  other  volatile  substances,  are 
more  or  less  prone  to  produce  redness  and  itching.  It  has,  how- 
ever, been  repeatedly  shown  that  this  irritating  property  of  the 
oils  on  the  higher  tissue  cells  is  much  more  pronounced  than  on 
the  lower  forms  of  life,  as  they  penetrate  the  cell  walls  of  the  higher 
organisms  much  more  rapidly  than  those  of  the  bacterial  cells. 
Administered  internally  in  well-diluted  form,  they  produce  a  feel- 
ing of  warmth,  and  may  give  rise  to  an  increased  appetite.  Aside 
from  their  physical  properties,  the  oils  may  act  also  by  virtue  of 
their  chemic  nature.  The  explanation  of  this  pharmacologic 
phenomenon  is,  in  most  instances,  at  present  unknown — that  is,  we 
do  not  know  why  certain  oils  (volatile  oil  of  mustard)  produce  such 
violent  irritation,  etc.  As  has  been  experimentally  shown  by 
Fischer,  certain  essential  oils — oils  of  cloves,  peppermint,  euca- 
lyptus, cassia,  etc. — produce  severe  irritation,  and,  if  the  applica- 
tion is  continued,  cause  atrophy  of  the  pulp.  It  is  apparently  im- 
material whether  the  oils  are  applied  directly  on  the  pulp  or  indi- 
rectly on  the  dentin.  The  obtundent  properties  of  certain  essential 
oils  which  Liebreich  has  classified  as  painful  atiestlietics  manifest 
themselves  at  first  by  severe  irritation,  which  is  followed  by  pro- 
nounced anesthesia.  This  primary  severe  irritation  of  the  delicate 
pulp  tissue  is  frequently  the  cause  of  its  final  death,  a  factor 
which  should  be  remembered  in  the  conservative  treatment  of  this 
organ. 

Some  of  the  essential  oils  of  the  family  myrtacece — as  oil  of 
eucalyptus,  oil  of  cajuput,  oil  of  myrtle,  etc. — possess  the  additional 
property  of  dissolving  gutta-percha.  This  property  is  attributed 
to  cineol,  the  active  constituent  of  these  oils. 

At  present  the  medicinal  value  of  the  essential  oils  is  graded 
according  to  the  amount  of  active  constituents  which  they  con- 
tain— as,  oil  of  cinnamon  should  contain  at  least  75  per  cent  of 
einnamic  aldehyd,  etc.^  Essential  oils  have  been  and  are  still 
quite  frequently  sophisticated  with  cheaper  substitutes.     The  fol- 


»  Charabot,  Dupont  et  Pilet:   I.es  Huiles  Essentialles,   1900. 


ANTISEPTICS  187 

lowing  statement  (1908),  made  by  a  prominent  distiller  in  the 
United  States,  helps  to  verify  this  fact  in  regard  to  at  least  one 
oil: 

"The  actual  production  of  true  wintergreen  leaf  oil  amounts  to 
only  an  infinitesimal  fraction  of  the  enormously  increased  demand 
for  the  article  (or  for  an  oil  so  labeled)  under  the  Food  and  Drug 
Act.  We  are  unable  to  procure  enough  of  it  to  fill  one  per  cent 
of  the  orders  that  come  to  us,  and  of  even  that  one  per  cent  the 
authenticity  could  not  be  absolutely  established.  We  have  there- 
fore preferred  not  to  attempt  to  handle  the  article  at  all;  and  we 
make  this  statement  merely  to  inform  hundreds  of  correspondents, 
to  whom  the  facts  stated  have  been  privately  communicated  be- 
fore, that  our  position  remains,  and  is  likely  to  continue  indefinite- 
ly to  remain,  unchanged." 

The  methods  for  the  detection  of  these  adulterations  have  been 
much  improved  within  the  last  decade.^  Volatile  oils  should  be 
kept  in  well-stoppered  amber-colored  bottles  in  a  dark,  cool,  and 
dry  place,  as  the  effect  of  heat  and  sunlight  may  spoil  the  best  oils 
within  a  few  weeks. 

The  value  of  essential  oils  as  dental  antiseptics  is  largely  over- 
estimated, as  has  been  repeatedly  shown  by  careful  experiments 
made  by  Miller,  Cook,  MaWhinney,  and  others.  The  late  Miller* 
especially  expressed  himself  very  definitely  on  this  particular 
point  as  follows: 

"According  to  my  own  views  it  would  be  a  misfortune  for 
dentistry  in  its  entirety  if  the  endeavor  to  replace  carbolic  acid 
by  the  essential  oils  should  succeed.  Personally,  I  am  convinced 
of  the  eminent  antiseptic  power  of  oil  ox  cassia  especially.  In  the 
last  few  years  I  have  made  experiments  with  this  particular  oil 
in  treating  diseased  teeth.  Lately  I  have  again  abandoned  it,  as 
in  many  cases  where  I  formerly  obtained  good  results  with  car- 
bolic acid  I  did  not  succeed  with  oil  of  cassia.  Also  in  many  other 
cases,  especially  in  pronounced  apical  root  irritation  as  a  result 
of  gangrene,  where  the  treatment  with  oil  of  cassia  was  a  failure 
I  have  occasionally  obtained   a  cure  in   a  short  time  with  car- 


1  Gildemeister  and  HoflFmann:  The  Essential  Oils.  1900. 
'Miller:    Die   Mikroorganismen    der    Mundhohle,    1892,    p.    224. 


1 88  PHARMACO-THERAPEUTICS 

bolic  acid.  I  feel  certain  that  I  have  used  the  oil  of  cassia  con- 
scientiously, and  in  the  beginning  I  had  even  a  special  liking  for 
this  medicament." 

In  the  present  routine  practice  of  conservative  dentistry  very 
few  essential  oils  are  utilized,  but  these  oils  should  be  of  the  best 
quality.  Better  results  are  obtained  from  the  application  of  their 
active  chemic  constituents — eugenol  instead  of  oil  of  cloves,  cin- 
namic  aldehyd  instead  of  oil  of  cassia,  eucalyptol  instead  of  oil 
of  eucalyptus,  methyl  salicylate  instead  of  oil  of  wintergreen. 
etc.  We  particularly  emphasize  what  we  have  already  stated 
(page  50)  in  regard  to  dental  drug  purchases — they  should  be  the 
product  of  a  reliable  manufacturer  and  purchased  only  in  original 
packages. 

MaWhinney^  has  recorded  a  series  of  experiments  relative  to 
the  antiseptic  value  of  the  essential  oils  and  other  drugs,  of  which 
the  following  is  an  abstract: 

"The  culture  medium  used  in  my  experiments  was  nutrient 
beef  bouillon,  carefully  made  and  sterilized  according  to  the  usual 
methods.  The  organisms  used  were  fresh,  pure  cultures  of  the 
staphylococcus,  except  when  otherwise  indicated.  The  reasons  for 
using  pure  cultures  were:  (1)  To  obtain  specific  action  on  the 
bacteria;  (2)  mixed  cultures  of  bacteria  and  their  products  so 
act  upon  each  other  as  to  lessen  their  resisting  i)ower  to  chemic 
agents.  The  reasons  for  using  the  staphylococcus  was  that  it  is 
the  organism  wdth  which  the  dentists  have  to  deal  most  fre- 
quently. The  organisms  were  distributed  carefully  throughout 
a  tube  containing  10  cubic  centimeters  of  nutrient  beef  bouillon 
(examination  made  to  see  that  colonies  were  broken  up  and  thor- 
oughly distributed).  A  loopful  of  this  was  transferred  to  each 
tube  containing  10  cubic  centimeters  of  the  medium,  into  which 
the  medicament  was  distributed  carefully,  weighing  the  amount 
used.  This  was  then  placed  in  the  incubator  and  kept  at  37°  C, 
and  examined  from  time  to  time." 

From  the  various  tables  accompanying  MaWhinney's  articles 
the  following  have  been  selected  on  account  of  their  complete- 
ness: 

»MaWhinney:   Transactions   Illinois   State   Dental    Society,   1900,   p.    125. 


ANTISEPTICS  -  189 

DETERMINATION  OF  THE  STRENGTH  OF  THE  ANTISEPTICS 


Medicament  used 


Amount  of 

medicament 

used 


Condition  in 
24  hours 


Condition  in 
96  hours 


Oil  cassia 

Oil  cinnamon 

Oil  peppermint 

Oil  cloves 

Oil  cajuput 

Black's  1-2-3 

Oil  wintergreen 

Oil  eucalyptus 

Oil  cedar 

Oil  cade 

Oil  birch  tar 

Phenol,  melted  crystals. .  . 
Creosote,  pure  beechwood, 

Campho-phenique 

Control  tube 

Creolin 

Trikresol 

Chinosol,  10-percent  sol. .  . 


/4  minims 


mmim 
2     minims 


Growth 
<< 

Slight  growth 

<<  (( 

Si  ti 

Growth 
<( 

Slight  growth 


Growth 
No  growth 


^  Marked  growth 
1      <i  << 

^  Growth 

^  Marked  growth 

"  Growth 
1       << 

3  << 

'  Slight  growth 

3  <  <  <  < 

3  <«  It 

"  Growth 

3  << 

'  Good  growth 

'  Very  marked  growth 

'  No  growth 


To  determine  the  strength  of  an  antiseptic  in  the  manner  pre- 
viously mentioned  (page  105)  is  by  no  means  sufficient  to  estab- 
lish the  fact  that  it  is  either  weal?  or  strong.  Painstaking  tests 
and  laborious  records  in  regard  to  the  time  of  the  exposure  of  the 
germs,  number  of  germs,  culture  media,  temperature,  etc.,  ai'e 
essential  factors  to  obtain  a  fair  amount  of  tangible  material  for 
comparison.  The  obtained  results  are,  it  should  be  remembered, 
only  laboratory  experiments,  and  the  deductions  '^rawn  should 
not  be  transferred  at  once  to  active  practice,  for  here  we  meet  with 
many  conditions  which  may  lead  to  totally  erroneous  conclusions 
in  regard  to  the  real  value  of  the  employed  antiseptic  if  these  new 
surroundings  are  not  carefully  taken  into  consideration.  For  this 
very  reason  it  is  not  surprising  that  so  many  contradictory  state- 
ments are  made  as  to  the  merit  of  any  particular  antiseptics. 

In  the  following  table  ''the  germicidal  power  of  the  medica- 
ments is  determined  by  the  time  necessary  to  expose  germs  to  it, 
and,  as  will  be  seen,  a  great  difference  appears.  It  will  be  noticed 
that  some  agents  were  used  in  full  strength  and  others  in  per  cent 
solutions,  according  as  they  could  be  used  in  practice.  The  germs 
used  were  mixed  pus  cultures." 


•  Oil  in  bottom  of  tube. 
-  Oil  on  top  of  broth, 
s  Soluble  still. 


190  PHAKMACO-THERAPEUTICS 

DETERMINATION  OF  THE  TIME  REQUIRED  FOR  ANTISEPTIC  ACTION 


Agent 

Percent  solution 

Time    required, 
minutes 

Oil  cassia 

Oil  cinnamon 

Full  strength 

1:1,000 

Full  strength 

1:250 

Full  strength 

10  percent 

Full  strength 

Saturated  alcoholic  solution 

40 
40 

Oil  cloves 

40 

Oil  cajuput 

45 

Oil  eucalyptus 

40 

Oil  wintergreen 

60 

Oil  peppermint 

50 

Oil  cade 

25 

Oil  birch  tar 

20 

Oil  pennyroyal 

45 

Phenol 

80 

Creosote,  beechwood 

;o 

Campho-phenique 

40 

Mercury  bichlorid 

25 

Creolin 

5 

Trikresol 

5 

Sublamin 

3 

Kresamin 

5 

Formalin 

2 

Chinosol 

Phenol-sulphonic  acid 

Tribromophenol 

Trichlorphenol 

1 

5 
10 

8 

The  following  table,  by  Miller/  indicates  the  concentration  in 
which  the  various  oils  can  be  used  in  the  mouth : 


Oil  of  Cloves 1:550 

Oil  eucalyptus 1 :750 

Oil  peppermint 1:600 


Oil  Cinnamon 1:400 

Oil  wintergreen 1 :350 

Eugenol 1:750 


Oil  pinus  pumillio 1:360    I    Thymol 1:2,000 

For  obvious  reasons,  only  those  oils,  their  derivatives,  and  syn- 
thetic substitutes  that  have  a  direct  relationship  to  the  practice 
of  dentistry  are  considered. 

Essential  Oils. 

Oil  of  Betula  (Oleum  Betul^,  U.  S.  P.). — Oil  of  sweet 
birch ;  essence  de  bouleau,  F. ;  Birkenrindenol,  G.  A  volatile  oil 
obtained  from  the  bark  and  the  leaf  buds  of  sweet  birch,  Betula 
lenta  Linne  (nat.  ord.  Betulacem).  It  is  a  colorless  or  yellowish 
liquid,  having  a  characteristic,  strongly  aromatic  odor  and  taste, 
closely  resembling  that  of  oil  of  wintergreen.  This  oil  is  identical 
with  methyl  salicylate,  and  equally  identical  with  oil  of  winter- 


*  Miller:   Die   Mikroorganismen   der   Mundhohle,    1892,   p.    223. 


ANTISEPTICS  191 

green,  for  which  it  is  frequently  substituted.  Average  dose,  15 
mimims  (1  C.c.). 

Oil  of  Cajuput  (Oleum  Cajuputi,  U.  S.  P.,  B.  P.). — Oil  of 
white  wood,  essence  de  cajeput,  F. ;  Cajeputol,  G.  A  volatile 
oil  distilled  from  the  leaves  and  twigs  of  Melaleuca  leucadendron 
Linne  (nat.  ord.  Myrtacem).  The  oil  of  cajuput  is  very  fluid  and 
transparent.  Usually  it  has  a  fine  green  color,  and  an  agreeable, 
distinctly  camphoraceous  odor.  Its  active  constituent  is  cineol 
(cajuputol),  a  chemic  body  of  which  it  should  contain  at  least 
55  per  cent,  and  which  is  identical  with  eucalyptol.  Oil  of  cajuput 
is  used  as  a  carminative,  stimulant,  diaphoretic,  and  counterir- 
ritant.     Average  dose,  8  minims   (0.5  C.c). 

Oil  of  Carav^ay  (Oleum  Cari,  U.  S.  P.,  B.  P.). — Essence  de 
carvi,  F. ;  Kiimmelol,  G.  A  volatile  oil  distilled  from  caraway, 
Carum  carvi  Linne  (nat.  ord.  Umhelliferm) .  The  oil  of  caraway 
is  somewhat  viscid,  of  a  pale,  yellowish  color,  becoming  brownish 
by  age,  and  with  an  odor  of  the  fruit  caraway.  Its  active  con- 
stituent is  carvacol  (carven)  ;  it  is  identical  with  carvol,  the 
active  constituent  of  the  oil  of  dill.  It  resembles  the  oil  of  cloves 
in  its  antiseptic  and  anodyne  action,  and  is  also  largely  used  as  a 
carminative.     Average  dose,  3  minims  (0.2  C.c.). 

Oil  of  Cinnamon;  Oil  of  Cassia  (Oleum  Cinnamomi,  U.  S. 
P.,  B.  P.). — Essence  de  cannelle,  F. ;  Zimmtol,  G.  A  volatile  oil 
distilled  from  cassia-cinnamon,  which  is  from  one  or  more  unde- 
termined species  of  cinnamon  grown  in  China  (nat.  ord.  Laurinece,) . 
Two  oils  of  cinnamon  are  found  in  commerce — ^one  procured  from 
the  Ceylon  cinnamon,  the  other  from  the  Chinese  cinnamon.  The 
latter  is  often  distinguished  by  the  name  of  oil  of  cassia.  There 
is  no  essential  difference  between  the  two  oils.  The  Chinese  oil 
is  much  cheaper  and  more  abundant,  although  not  so  fine  in  flavor 
as  the  Ceylon  product.  It  is  a  yellowish  or  brownish  liquid,  be- 
coming darker  and  thicker  with  age  and  exposure  to  the  air,  hav- 
ing the  characteristic  odor  of  cinnamon,  and  a  sweetish,  spicy,  and 
burning  taste.  The  medicinal  properties  of  cinnamon  oil  depend 
solely  on  the  amount  of  cinnamic  aldehyd  present.  A  good  oil 
should  contain  at  least  75  per  cent  of  cinnamic  aldehyd.  The  lat- 
ter, by  moderate  oxidation,  forms  cinnamic  acid,  but,  by  more  ener- 
getic action,  benzoic  acid  is  produced.  Quite  a  number  of  other 
chemic  bodies — as  eugenol,  pinen,  etc. — have  been  isolated  from 
this  oil.    They  are,  however,  present  only  in  very  small  quantities. 


192  PHARMACO-THERAPEUTICS 

Cinnamon  oil  is  used  principally  as  a  flavoring  agent,  and  in  den- 
tistry as  an  antiseptic.  It  possesses  carminative  and  stimulating 
qualities.  Of  all  the  essential  oils,  oil  of  cinnamon  is  the  one  which 
has  received  the  highest  praise  as  an  antiseptic  for  the  treatment 
of  putrescent  root  canals,  and  some  practitioners  have  gone  even 
so  far  as  to  place  its  comparative  antiseptic  power  above  that  of 
phenol.  This  praise  is  partially  the  result  of  erroneous  clinical 
observations  and  partly  of  empirical  conclusions.  The  late  Miller 
expressed  himself  very  distinctly  on  this  particular  point.  (See 
page  187.)  Oil  of  cinnamon,  like  most  of  the  essential  oils,  pene- 
trates the  tooth  structure  very  readilj^  usually  discoloring  the 
tooth  to  a  yellowish-brown  hue,  resulting  from  the  deposition  of  a 
resinous  substance,  furfurol,  in  its  tubules.  Harlan  claimed  that 
ozonized  oil  of  turpentine  will  remove  such  stains  from  the  teeth ; 
however,  the  oxj'^gen  liberating  compounds  are  best  suited  for 
such  purposes.  (See  Bleaching  Agents.)  If  oil  of  cinnamon  is 
used  at  all  for  the  treatment  of  devitalized  teeth,  the  s.vnthetic  oil, 
or  Merck's  "two-fold,  free  from  terpene,  oil  of  cassia,"  should  be 
employed.    Average  dose,  1  minim  (0.05  C.c). 

Oil  of  Clove  (Oleum  Caryophylli,  U.  S.  P.,  B.  P.). — Es- 
sence de  giroffle,  F. ;  Nelkenol,  G.  A  volatile  oil  distilled  from 
cloves,  Eugenia  aromaiica  Linne  (nat.  ord.  Myrtacem).  Oil  of 
cloves,  when  recently  distilled,  is  very  fluid,  clear,  and  colorless, 
but  becomes  yellowish,  and  finally  leddish-brown  and  thick  with 
age.  Its  medicinal  properties  depend  on  the  presence  of  eugenol. 
a  monatomic  phenol,  of  which  a  good  oil  should  contain  at  least 
80  per  cent.  The  value  of  quite  a  number  of  other  oils  also  de- 
pends chiefly  on  the  presence  of  eugenol — as  cinnamon  leaf  oil, 
oil  of  bay,  oil  of  pimenta,  etc.  Oil  of  cloves  enjoys  an  old  and 
well-earned  reputation  of  being  a  valuable  obtunding  rcmedj'^  in 
the  treatment  of  toothache  arising  from  an  irritated  pulp.  It 
also  possesses  stimulating  and  antiemetic  properties.  Average 
dose,  3  minims  (0.2  C.c). 

Oil  of  Eucalyptus  (Oleum  Eucalypti,  U.  S.  P.,  B.  P.). — 
Essence  de  eucalyptus,  F. ;  Eucalyptusol,  G.  A  volatile  oil  dis- 
tilled from  the  fresh  leaves  of  eucalyptus  (nat.  ord.  Myrtacem). 
Oil  of  eucalyptus  is  a  colorless  or  pale  yellow  liquid,  with  a  char- 
acteristic, aromatic,  and  somewhat  eamphoraceous  odor,  having 
a  pungent,  spicy,  and  cooling  taste.  The  value  of  this  oil  depends 
on  the  amount  of  cucalyptol  (cincol)   present,  of  which  it  should 


ANTISEPTICS  193 

contain  at  least  60  per  cent.  As  an  antiseptic,  oil  of  eucalyptus  is 
practically  valueless.    Average  dose,  8  minims  (0.5  C.c). 

Oil  op  Gaultheria  (Oleum  Gaultheri^,  U.  S.  P.). — Oil  of 
wintergreen;  oil  of  tea  berry;  oil  of  partridge  berry;  Winter- 
gruenol,  G.  A  volatile  oil  distilled  from  the  leaves  of  GauWieria 
procumhens  (nat.  ord.  Ericacece,).  It  consists  almost  entirely  of 
methyl  salicylate,  and  is  nearly  identical  with  the  volatile  oil  of 
betula  (sweet  birch).  Wintergreen  oil  possesses  little  value  as  an 
antiseptic.  It  is  used  as  a  substitute  for  salicylic  acid  in  its  in- 
ternal administration.  It  is  slightly  stimulating  and  astringent  in 
its  effect,  and  is  much  in  favor  as  a  flavoring  agent  for  mouth 
specialties — as  dentifrices,  cachous,  chewing  gums,  etc.  Average 
dose,  15  minims  (1  C.c). 

Oil  of  Mustard,  Volatile  (Oleum  Sinapis  Volatile,  U.  S.  P.). 
Volatile  oil  of  mustard ;  essence  de  moutarde,  F. ;  atherisches 
Senfol,  G,  A  volatile  oil  obtained  from  black  mustard,  the  seed  of 
Brassica  nigra,  by  maceration  with  water  and  subsequent  distilla- 
tion. It  is  a  very  powerful  irritant,  and  its  use  is  limited  to  ex- 
ternal application  in  alcoholic  solutions.  It  is  the  active  agent  of 
the  mustard  plaster.  It  is  said  to  be  of  assistance  in  the  removal 
of  the  odor  of  iodoform  from  the  hands,  etc.  Average  dose,  Vs 
minim  (0.008  C.c). 

Oil  of  Myrcia  (Oleum  Myrci^). — Oil  of  bay;  essence  de  bay, 
F. ;  Bayol,  G.  A  volatile  oil  distilled  from  Myrcia  acris  (nat.  ord. 
Myrtacece) .  This  oil  resembles  very  closely  the  oil  of  pimenta  and 
oil  of  cloves.  Its  medicinal  value  depends  on  the  amount  of 
eugenol  present.  On  account  of  its  fragrance  it  is  largely  used  as 
a  perfume  and  as  an  ingredient  in  the  preparation  of  bay  rum. 

Oil  of  Peppermint  (Oleum  Mentha  Piperita,  U.  S.  P.,  B. 
P.).  Essence  de  menthe  poivree,  F. ;  Pfefferminzol,  G.  A  volatile 
oil  distilled  from  peppermint,  Mentha  piperita  (nat.  ord.  Lahiatce),. 
The  oil  of  peppermint  is  colorless,  or  of  a  light  greenish-yellow 
color,  which  becomes  reddish  by  age.  Its  odor  is  strong  and 
aromatic  Its  taste  is  warm,  camphoraceous,  and  very  pungent, 
but  succeeded,  when  air  is  admitted  into  the  mouth,  by  a  sense  of 
coolness.  The  medicinal  properties  of  this  oil  depend  on  the 
menthol  present,  of  which  it  should  yield  50  per  cent.  Oil  of  pep- 
permint is  stimulating  and  carminative,  and  is  largely  used  as  an 
external  remedy  in  facial  and  other  neuralgic  pain.  On  account 
of  its  odor  it  is  rarely  employed  as  an  antiseptic,  but  is  much  used 


194  PHARMACO-THERAPEUTICS 

as  a  flavoring  agent  for  oral  specialties.     Average  dose,  3  minims 
(0.2  C.C.). 

Oil  of  Thyme  (Oleum  Thymi,  U.  S.  P.). — Essence  de  thyme, 
F. ;  Thymianol,  G.  A  volatile  oil  distilled  from  the  leaves  and 
flowering  tops  of  Thymus  vulgaris  (nat.  ord.  Labiatce).  Drug- 
gists list  two  varieties  of  this  oil,  the  white  and  the  red,  the  white 
oil  being  a  purified  product  of  the  crude  red  oil.  Often  a  crude 
oil  is  imported  from  France  under  the  name  of  oil  of  thj-me  that 
is  oil  of  origanum  (wild  marjoram).  The  medicinal  properties  of 
oil  of  thyme  depend  on  the  thymol  present,  of  which  it  should 
yield  not  less  than  20  per  cent.  The  oil  is  used  as  an  antiseptic 
and  irritant  in  external  applications.  Average  dose,  3  minims 
(0.2  C.c). 

Oil  of  Ylang  Ylang  (Oleum  Cananga). — Oil  of  ylang  ylang 
is  distilled  in  Manila  from  the  flowers  of  Cananga  odorata  (nat. 
ord.  ArionacecB).  This  oil  is  especially  noted  for  its  delicious  per- 
fume. It  seems  to  be  a  complex  mixture,  and  the  following  bodies 
have  been  found  in  the  oil:  The  esters  of  benzoic  and  salicylic 
acids,  eugenol,  iso-eugenol,  geraniol,  pinen,  small  quantities  of 
paracresol,  etc.  Ottofy,  of  Manila,  P.  I.,  speaks  very  highly  of  the 
antiseptic  and  obtunding  qualities  of  this  oil,  claiming  that  it  is 
superior  in  its  medicinal  virtues  to  all  the  other  essential  oils  that 
he  has  used  in  his  practice.  Oil  of  cananga  is  a  less  fragrant  oil  of 
ylang  ylang,  prepared  from  the  same  plant  in  Java. 

Derivatives  and  Synthetic  Substitutes  of  Essential  Oils. 

Borneol,  CioHigO. — Artificial  blumea  camphor  of  the  Chinese; 
Borneo  camphor;  borneol,  F. ;  Borneol,  G.  A  colorless,  crystalline 
substance,  having  an  odor  somewhat  different  from  that  of  ordinary 
camphor,  resembling  the  odor  of  patchouly  or  ambergris.  It  is 
readily  soluble  in  alcohol,  chloroform,  etc.,  but  insoluble  in  water. 
It  possesses  antiseptic  properties. 

Camphor;  Camphor,  U.  S.  P.,  B.  P.;  CioHigO. — Camphre,  F. ; 
Kampher,  G.  Camphor  is  a  stearopten  obtained  from  the  volatile 
oil  of  the  camphor  tree,  Cinnamomum  camplwra.  It  forms  white 
translucent,  crystalline  masses,  w^hich  are  almost  insoluble  in  water, 
but  dissolve  readily  in  alcohol,  ether,  chloroform,  and  in  fixed  and 
volatile  oils.  It  is  incompatible  with  phenol,  thjTnol,  hydrated 
chloral,  menthol,  resorcinol,  etc.,  in  dry  triturations,  and  liquefies 


ANTISEPTICS  195 

these  substances  when  brought  in  contact  therewith.    Average  dose, 
2  grains  (0.125  Gm.). 

Therapeutics. — On  the  skin  and  mucous  membrane  camphor 
acts  as  a  mild  irritant.  It  produces  redness  and  a  feeling  of 
warmth  when  rubbed  into  the  skin,  and  is  principally  applied  ex- 
ternally in  the  form  of  alcoholic  solutions  or  as  a  liniment  (cam- 
phorated oil).  It  possesses  slight  antiseptic  action,  and  is  fre- 
quently used  to  modify  the  caustic  action  of  phenol,  thymol, 
resorcinol,  etc.  Internally  it  is  used  as  a  stimulant  of  the  central 
nervous  system,  and  is  especially  indicated  in  collapse  arising 
from  the  action  of  general  anesthetics,  or  from  depression  and 
weakness.  In  such  cases  it  acts  as  an  analeptic  by  increasing  the 
heart  action.  It  is  usually  injected  hypodermically  in  sterilized 
solutions  of  olive  oil. 

Carvon,  CjoHi^O. — Carvone,  F. ;  Carvon,  G.  A  keton  form- 
ing the  essential  constituent  of  the  oil  of  caraway  seed  and  oil  of 
dill.  It  is  a  pale  yellow  liquid,  having  the  fine  odor  of  caraway 
seed.  It  is  used  as  a  substitute  for  the  oil  of  caraway  and  oil  of 
dill. 

CiNNAMic  Aldehyd;  Cinnaldehydum,  U.  S.  p.,  CsHgCH: 
CHCHO. — Aldehyde  cinnamique,  F. ;  Zimmtaldehyd,  G.  An  alde- 
hyd obtained  from  oil  of  cinnamon,  or  prepared  synthetically. 
The  oil  should  contain  at  least  75  per  cent  of  cinnamic  aldehyd. 
It  is  a  colorless  liquid,  having  a  cinnamon-like  odor  and  a  burning, 
aromatic  taste.  It  is  sparingly  soluble  in  water,  soluble  in  all  pro- 
portions in  alcohol,  ether,  and  fixed  and  volatile  oils.  It  is  largely 
used  as  a  substitute  for  the  various  oils  of  cinnamon  in  the  treat- 
ment of  putrescent  root  canals.  Cinnamic  aldehyd  will  not  discolor 
tooth  substance,  which  is  frequently  observed  when  oil  of  cassia 
is  used.    Average  dose,  1  minim  (0.05  C.c). 

EucALYPTOL;  EucALYPTOL,  U.  S.  P.;  CioHigO. — Cincol,  caju- 
putol,  eucalyptus  camphor;  eucalyptol,  F.,  G.  A  neutral  body  ob- 
tained from  the  volatile  oils  of  Eucalyptus  globulus  and  from 
various  other  sources.  It  is  a  colorless  liquid,  congeals  below  32° 
F.  (0°  C),  having  a  camphor-like  odor  and  a  pungent,  spicy,  and 
cooling  taste.  It  is  identical  with  cajuputol  and  cineol.  It  is 
soluble  in  alcohol,  ether,  chloroform,  etc.,  but  insoluble  in  water. 
It  is  very  mildly  antiseptic,  antispasmodic,  expectorant,  and  anti- 
periodic;  in  combination  with  menthol  and  other  bodies  of  a 
similar  nature  it  is  much  in  favor  as  an  inhalent  or  as  a  spray 


196  PHARMACO-THERAPEUTICS 

diluted  with  a  bland  oil  in  bronchitis,  asthma,  pneumonia,  rhinitis. 
It  does  not  possess  anesthetic  properties.  Average  dose,  5  minims 
(0.3  C.c). 

Therapeutics. — Eucalyptol  is  practically  nonirritant.  In  con- 
nection with  cotton  it  is  a  valuable  agent  for  the  temporary  filling 
of  root  canals  which  require  observation.  As  a  lubricant  for 
gutta-percha  cones  for  the  filling  of  root  canals  it  is  to  be  recom- 
mended. Eucalyptol  will  dissolve  gutta-percha.  If  a  perfect  solu- 
tion is  desired,  the  gutta-percha  should  be  first  dissolved  in  chloro- 
form, and  then  an  equal  amount  of  eucalyptol  added,  the  bottle 
being  left  open  until  the  chloroform  is  evaporated.  This  solution 
is  superior  to  the  so-called  chloro-percha — a  solution  of  gutta-percha 
in  chloroform.     (See  Protectives,  Demulcents,  and  Emollients.) 

Modified  Eucalyptol. 

U     Menthol.  gr.  ij    (0.12  Gin.) 

ThjTnol.  gr.  iij    (0.18)   Gm.) 

Eucalyptol.  3  j   (4  C.c.) 

M. 

Sig. :     To  be  used  in  infected  root  canals. 

(Buckley.) 

EuGENOL;  EuGENOL,  U.  S.  P.;  C^oHj^^^^- — Eugcnic  acid,  cary- 
ophylic  acid;  eugenol,  F.,  G.  An  unsaturated,  aromatic  phenol, 
obtained  from  oil  of  cloves  and  other  essential  oils.  A  colorless  or 
pale  yellow  liquid,  highly  refractive,  becoming  brown  on  exposure 
to  air,  and  having  a  strong  aromatic  odor  of  cloves  and  a  pungent, 
spicy  taste.  It  is  soluble  in  alcohol,  ether,  chloroform,  and  diluted 
solutions  of  caustic  soda;  insoluble  in  water.  It  possesses  antisep- 
tic, stimulating,  and  local  anesthetic  properties.  It  is  largely  used 
as  a  substitute  for  oil  of  cloves.    Average  dose,  3  minims  (0.2  C.c). 

Therapeutics. — Eugenol  is  equally  as  strong  an  antiseptic  as 
phenol,  possessing  decidedly  less  cauterant  properties.  It  is  an 
excellent  anesthetic  for  the  treatment  of  pain  arising  from  an  ir- 
ritated or  diseased  pulp,  either  alone  or  in  combination  with  other 
suitable  remedies.  In  the  form  of  a  paste  it  is  recommended  as  a 
means  of  capping  the  exposed  pulp  or  as  a  temporary  filling  in 
hypersensitive  cavities.  In  preparing  such  temporary  cements, 
rather  large  quantities  of  eugenol  must  be  incorporated  into  the 
powder.  Combined  with  f ormaldehyd  solution,  it  is  recommended 
for  the  treatment  of  putrescent  root  canals.    To  isolate  the  strong 


ANTISEPTICS  197 

anesthetic  properties  from  eugenol,  as  the  latter  still  acts  as  a 
mild  cauterant,  a  number  of  compounds  have  been  prepared  syn- 
thetically, among  which  the  p-amino-benzoie  acid  has  been  found 
to  be  of  the  utmost  importance.  If  this  acid  is  combined  with  cer- 
tain esters,  it  furnishes  the  basis  on  which  some  of  the  most  im- 
portant local  anesthetics  have  been  constructed.  Combined  with 
ethyl  ester,  it  forms  anesthesin,  and,  in  another  modification, 
orthoform,  while  the  hydrochlorid  of  its  di-ethyl-amino-ethanol 
ester  is  known  as  novocain.  The  simple  p-amino-benzoyl  eugenol, 
which  is  also  a  strong  anesthetic  and  antiseptic,  appears  in  slightly 
yellowish  or  white  prisms,  which  are  readily  soluble  in  alcohol  and 
ether,  but  insoluble  in  water.  In  the  form  of  a  temporary  cement, 
known  as  a  plecavol,  it  is  employed  as  a  temporary  filling  in  pain- 
ful conditions  of  the  pulp  arising  from  dental  caries,  and  as  a 
root  filling  material. 

Pulp  Capping  Paste. 

I^     Aristol  or  europhen  3  j    (4  Gm.) 

Calcium  phosphate  3  x  (40  Gm.) 

Eugenol  enough  to  make  a  creamy  paste. 

Menthol;  Menthol,  U.  S.  P.,  B.  P.,  CioHgoO. — Camphore  de 
menthe,  F. ;  Pfefferminzkampfer,  G.  A  stearopten  (camphen), 
having  the  character  of  a  saturated  secondary  alcohol  obtained 
from  the  official  or  from  the  Chinese  or  Japanese  oil  of  pepper- 
mint. Japanese  menthol  appears  in  colorless  crystals  or  in  fused 
crystalline  masses,  having  a  strong  odor  of  peppermint  and  a 
warm,  aromatic  taste,  followed  by  a  sensation  of  cold  when  air  is 
drawn  into  the  mouth.  It  melts  at  about  110°  F.  (43°  C).  It 
is  slightly  soluble  in  water,  but  freely  soluble  in  alcohol,  ether, 
chloroform,  etc.  It  possesses  very  weak,  antiseptic,  anesthetic,  and 
analgesic  properties.  Menthol  in  the  shape  of  compressed  cones 
or  combined  in  an  ointment  is  largely  employed  for  the  relief  of 
neuralgic  pains.  When  applied  to  the  skin,  it  produces  at  first 
slight  pain,  with  a  sensation  of  cold  and  benumbing  the  skin.  It 
is  largely  used  as  a  substitute  for  oil  of  peppermint. 

Methyl  Salicylate. — Artificial  or  synthetic  oil  of  wintergreen; 
salicylate  de  methyl,  F. ;  Kiinstliches  Wintergruenol,  G.  A  color- 
less or  slightly  yellowish  liquid,  having  a  characteristic,  strong 
aromatic  odor  and  a  sweetish,  warm  taste.    It  is  at  present  almost 


198  PHARMACO-THERAPEUTICS 

universally  used  as  a  substitute  for  the  natural  oil  of  vvintergreen 
or  oil  of  sweet  birch. 

Myrtol. — A  compound  prepared  by  the  fractional  distillation 
of  oil  of  myrtle,  consisting  largely  of  cineol,  and  therefore  almost 
identical  with  eucalyptol  and  cajuputol.  It  is  used  as  a  substitute 
for  oil  of  myrtle. 

Thymol:  Thymol,  U.  S.  P.,  B.  P.,  CioHi.O.— Thymic  acid, 
thymecamphor,  methylnormalpropylphenol ;  acide  thymique,  F. ; 
Thymol,  G.  Thymol  is  a  phenol  of  the  benzol  series,  occur- 
ring in  the  volatile  oil  of  Tliymus  vulgaris  and  other  volatile 
oils.  It  appears  in  colorless,  crystalline  masses,  having  an  aromatic, 
pungent,  and  slightly  caustic  taste,  and  is  of  nearly  neutral  reac- 
tion. It  is  practically  nontoxic.  It  melts  at  about  122°  F.  (50° 
C),  is  slightly  soluble  in  water  (1:1,100),  but  very  readily  soluble 
in  alcohol,  ether,  essential  and  fatty  oils,  chloroform,  glacial  acetic 
acid,  etc.  When  treated  with  camphor,  menthol,  chloral,  etc.,  it 
liquefies.  In  its  local  action  it  closely  resembles  phenol  and  salicylic 
acid.  It  is  not  as  caustic  as  phenol,  but  more  destructive  to  putre- 
factive substances. 

Therapeutics. — ^Thymol  received  its  first  attention  by  M.  Bouil- 
lon, a  French  pharmacist,  and  soon  after  it  was  introduced  into 
general  medicine  (1876).  Thymol  has  been  highly  recommended 
by  dental  practitioners,  and  its  valuable  antiseptic  properties  have 
been  sustained.  In  combination  with  other  similar  remedies,  it  is 
to  be  recommended  on  account  of  its  persistent  action.  A  saturated 
alcoholic  solution  of  thymol  is  recommended  by  Hirsch  as  a  specific 
for  the  treatment  of  chronic  alveolar  abscesses.  Its  irritating  na- 
ture prohibits  its  use  in  acute  pericementitis.  The  following  solu- 
tion, known  as  thymocamphene,  has  given  universal  satisfaction 
for  the  treatment  of  putrescent  root  canals: 

ft     Thymol         *  3  j   (4  Gm.) 

Phenol  3  j   (4  Gm.) 

Camphor  3  ss  (2  Gm.) 

Place  the  drugs  in  a  dry  amber-colored  bottle.     They  will 
soon  liquefy  and  remain  liquid. 

Kohler  recommends  the  following  combination  for  the  above  pur- 
pose: 


ASTRINGENTS  199 

ft     Thymol  3  j    (4  Gm.) 

Mono-chloro-phenol  3  iij    (12  Gm.) 

Potassium  hydroxid  3  j    (4  Gm.) 

Dissolve  the  thymol  in  the  liquefied  mono-chloro-phenol  and 
add  to  the  solution  the  potassium  hydroxid.  Carefully  heat 
over  a  low  Bunsen  flame  until  a  perfect  solution  is  produced. 
Immediately  transfer  to  small,  perfectly  dry  bottles,  wliich 
should  be  protected  by  paraflSned  stoppers. 

To  Miller  belongs  the  credit  of  first  recommending  thymol  in 
combination  with  other  chemicals  as  a  medicament  for  the  mum- 
mifying of  pulp  tissue.  In  alcoholic  solution  it  is  much  lauded 
as  a  mouth  wash. 

Thymotal. — According  to  Pool  it  is  a  tasteless  derivative  of 
thymol  for  internal  administration.  It  is  soluble  in  alkaline  iriedia 
only. 

ASTRINGENTS. 

Astringents  (from  stringer e,  to  bind)  are  substances  which, 
when  brought  in  contact  with  a  wound  or  a  mucous  surface,  cause 
the  formation  of  a  thin,  skin-like  protective  film.  The  film  results 
from: 

1.  The  drying  up  and  combining  of  the  astringent  with  the 
secretions. 

2.  The  coagulation  of  fibrogenous  substances. 

3.  The  precipitation  of  albuminous  substances. 

4.  The  chemic  change  of  the  tissue  known  as  "tanning." 

The  term  astringent  is  usually  interpreted  as  drawing  together. 
While  all  astringents  possess  in  a  more  or  less  marked  degree  this 
peculiar  property  so  easily  recognizable  by  the  taste,  and,  if  ap- 
plied in  concentrated  solution,  by  the  naked  eye,  it  should  be  re- 
membered that  it  is  only  a  symplom  of  the  astringent  action  as  a 
whole.  If  astringents  are  applied  in  concentrated  solutions,  they 
precipitate  proteins.  The  precipitated  albumins  form  a  protective 
layer  over  the  wound  or  the  mucous  surfaces,  while  the  deeper 
structures  are  contracted,  thus  causing  a  shrinkage  of  the  entire 
tissue  mass,  which  gives  to  the  smooth,  succulent  surface  a  dry, 
dense  character.  This  favorable  influence  of  astringents  is 
especially  noticeable  on  inflamed  soft  tissues  that  have  become 
morbidly  relaxed.  The  wound  or  inflamed  mucous  surfaces  are 
tanned,  a  chemic  process  which  is  analogous  to  tanning  hide  into 


200  PHARM  A  CO-THERAPEUTICS 

leather.  Formaldehyd  produces  a  similar  action;  the  resultant 
chemic  change  differs  from  the  true  tanning,  however,  in  so  far  as 
in  genuine  leather  the  tannic  acid  may  be  recovered,  while  from 
the  formaldehyd-albumin  combination  the  former  can  not  be  re- 
moved. 

The  astringent  action  of  drugs  manifests  itself  in  a  combination 
of  three  definite  ways : 

1.  By  contracting  the  muscular  coat  of  the  arterioles. 

2.  By  diminishing  the  secretion  and  transudation. 

3.  By  checking  the  migration  of  leucocytes — the  formation  of 
pus. 

The  simple  constriction  of  vessels  is  by  no  means  identical  with 
astringent  action;  for  example,  eocain  and,  more  so,  adrenalin  are 
very  powerful  vaso-constrictors  without  producing  the  true  astring- 
ent effect.  The  diminished  secretion  and  transudation,  and  the 
checking  of  the  migration  of  the  leucoej'tes,  result  from  the  tan- 
ning of  the  intercellular  cement  substance  between  the  endothelial 
cells,  producing  dense  fibers  of  preciptated  albumin,  which  block 
the  passage  of  fluids  or  semi-solid  materials.  On  unbroken  skin, 
astringents  act  very  slowly  and  in  a  much  milder  degree. 

If  an  astringent  is  dissolved  in  a  surplus  of  blood,  serum,  or 
other  tissue  fluid,  its  typical  action  is  destroyed.  Absorbed  astrin- 
gents produce  no  effect  through  the  circulation,  and  consequently 
their  internal  administration  for  the  purpose  of  acting  through 
the  blood  is  irrational. 

Astringent  action  is  primarily  manifested  by  the  salts  of  the 
heavy  metals,  by  tannic  acid  and  its  many  modifications,  and  by 
some  very  diluted  organic  and  inorganic  acids.  Those  metallic 
salts  which  are  readily  soluble  in  water,  and  which  are  weak  pro- 
toplasm poisons,  are  frequently  employed  as  astringents.  A  few 
insoluble  or  less  readily  soluble  metallic  salts,  like  the  salts  of 
bismuth  and  zinc  oxid,  are  also  employed  as  astringents,  and  are 
frequently  used  as  drying  agents.  The  vegetable  astringents  are 
represented  by  tannic  acid  and  its  innumerable  ill-defined  modifica- 
tions; they  also  precipitate  proteins,  gelatin,  alkaloids,  and  many 
glucosids.  The  acids  are  at  present  rarely  employed  as  astringents, 
with  the  possible  exception  of  diluted  acetic  acid  (vinegar),  citric 
acid  (lemon  juice),  and  weak  solutions  of  boric  acid.  Diluted  al- 
cohol and  glycerin  are  sometimes  employed  for  astringent  pur- 
poses; they  act  by  virtue  of  their  great  affinity  for  water.     In  the 


ASTRINGENTS 


201 


following  table  Schuqtz  has  recorded  the  diminution  of  the  secre- 
tion as  produced  by  the  weakest  concentration  of  the  employed 
astringent : 


Tannic   acid    0.05  per  cent 

Alum    0.06  per  cent 

Corrosive  sublimate 0.1  per  cent 

Hydrochloric  acid    0.12  per  cent 

Lead   acetate    0.22  per  cent 

Silver  nitrate   0.25  per  cent 


Sulphuric  acid    0.5  per  cent 

Iron  chlorid    0.5  per  cent 

Copper    sulphate    0.6  per  cent 

Zinc  sulphate   0.6  per  cent 

Acetic  acid   0.8  per  cent 

Tartaric  acid    4.0  per  cent 


Astringents  are  closely  related  to  caustics,  styptics,  antiseptics, 
and  protectives;  the  difference  in  their  action  is  largely  a  matter 
of  degree  as  regards  the  concentration  of  their  solutions. 

Astringents  are  employed  to  protect  wounded  or  inflamed  mu- 
cous surfaces,  to  check  hypersecretion,  to  contract  superficially  lo- 
cated blood  vessels,  and  to  reduce  swollen  mucous  surfaces.  All 
astringents  coagulate  blood  very  rapidly  when  they  are  brought 
in  intimate  contact  with  it,  and  consequently  they  are  used  as 
styptics.  They  are  frequently  employed  for  the  purpose  of  dimin- 
ishing small,  soft  tumors  of  the  mucous  linings.  Internally  they 
are  employed  for  the  treatment  of  diarrhea  and  dysentery. 

Metallic  Astringents. 

Copper  Sulphate  ;  Cupri  Sulphas,  U.  S.  P.,  B.  P. ; 
CUSO4+5H2O. 

Etymology. — After  Pliny,  "ms  cuprium,  an  ore  primarily  found 
in  Cyprus." 

Synonyms. — Cupric  sulphate,  blue  vitriol,  blue  stone;  sulfate 
de  cuivre,  F. ;  Kupfersulfat,  blauer  Galitzenstein,  Gr. 

Source  and  Character. — Copper  sulphate  is  obtained  by  the 
interaction  of  water,  sulphuric  acid,  and  copper  or  copper  oxid. 
It  has  a  rich,  blue  color,  a  strong  metallic  taste,  and  appears  in 
large  crystals,  which  slowly  effloresce  in  dry  air.  It  is  odorless, 
soluble  in  about  2.5  parts  of  water,  3.5  parts  of  glycerin,  very 
soluble  in  boiling  water,  and  almost  insoluble  in  alcohol.  It  is 
incompatible  with  alkalies  and  their  carbonates,  lime  water,  iodids, 
mineral  salts  (except  sulphates),  and  most  vegetable  astringents. 
It  attacks  steel  instruments. 

Average  Dose. — As  an  astringent,  %  grain  (0.01  Gm.)  ;  as  an 
emetic,  4  grains  (0.25  Gm.). 


202  PHARMACO-THERAPEUTICS 

Medical  Properties. — Astringent,  stimulant,  antiseptic,  caustic, 
and  emetic. 

Therapeutics. — Copper  sulphate,  like  all  other  metallic  salts, 
precipitates  albumin,  producing  a  superficial  film  of  copper  albu- 
minate. On  exposed  mucous  membranes  it  acts  as  a  caustic  and 
strong  astringent.  It  is  milder  in  its  action  than  silver  nitrate  or 
zinc  chlorid.  Administered  internally,  by  its  irritating  effect  on 
the  mucous  membrane  of  the  stomach,  it  acts  as  a  rapid  direct 
emetic,  and  is  well  suited  for  that  purpose  when  the  stomach  is  to 
be  surely  and  promptly  emptied  of  a  poison,  like  opium,  etc.  It 
is  an  active  antidote  in  acute  phosphorus  poison;  it  does  not  act 
merely  as  an  emetic,  but  it  partially  oxidizes  the  phosphorus  and 
partly  covers  it  with  metallic  copper  as  a  result  of  the  reduction 
produced  by  the  pieces  of  phosphorus.  When  it  is  administered 
for  a  longer  period,  it  may  cause  greenish  discoloration  of  the 
teeth,  but  not  of  the  gums. 

Copper  sulphate  is  used  in  I/2  to  2  per  cent  solutions  as  a  stimu- 
lating astringent  for  indolent  ulcers,  the  antrum,  etc.  It  is  highly 
recommended,  and  by  some  considered  a  specific,  for  the  treatment 
of  pyorrhea  alveolaris.  After  the  thorough  removal  of  calcareous 
deposits  from  the  roots  of  the  teeth,  the  pockets  are  cleansed  with 
an  antiseptic  solution,  and  the  finely  powdered  copper  sulphate, 
mixed  with  water  into  a  thick  paste,  is  pushed  into  the  pockets  by 
means  of  a  toothpick  or  a  looped  platinum  wire.  Cook^  recom- 
mends for  such  purposes  a  saturated  solution  of  the  salt  in  lactic 
acid.  Applied  on  carious  dentin  as  a  sterilizing  agent,  it  is  very 
likely  to  stain  the  tooth  a  permanent  greenish-blue.  Copper  sul- 
phate enjoys  a  wide  and  well-deserved  reputation  as  a  means  of 
destroying  lower  forms  of  life  in  polluted  water.  The  much  heard 
of  cry  of  "poisoning  with  copper"  is  wholly  unfounded,  as  the 
quantity  necessary  to  purify  water  (1:500,000)  is  too  small  to 
cause  any  serious  effects  on  the  health  of  the  consumer. 

Cuprol.  It  is  a  nuclein  of  copper,  containing  about  6  per  cent 
of  the  latter.  It  is  a  green  powder,  readily  soluble  in  water.  Its 
solution  does  not  coagulate  albumin. 

Alum  and  burnt  alum  are  useful  astringents  on  wound  sur- 
faces, etc.  Solution  of  aluminum  acetate,  containing  about  8  per 
cent  of  aluminum  acetate,  is  much  lauded  as  a  mouth  wash   (a 


*Ccok:  American  Dental  Journal,  1905,  p.  205. 


ASTRINGENTS  203 

tablespoonful  in  a  glassful  of  water)    in  all  conditions  where  a 
mild,  yet  positive,  astringent  is  indicated. 

Lead  Acetate;  Plumbi  Acetas,  U,  S.  P.,  B.  P.;  PbCCgHgOa)-^ 
+3H2O;  Sugar  of  Lead;  Sucre  de  Saturne,  F. ;  Bleizucker, 
G. 

It  forms  colorless  shining  crystals,  having  a  sweetish,  astringent, 
afterward  metallic  taste.  It  is  soluble  in  2  parts  of  water  and  30 
parts  of  alcohol.  Exposed  to  the  air,  it  effloresces  and  absorbs  car- 
bon dioxid.  It  is  incompatible  with  acids,  sulphates,  chlorids,  tan- 
nin, phenol,  and  vegetable  infusions  and  tinctures.  Lead  acetate 
is  poisonous. 

Average  Dose. — 1  grain  (0.06  Gm.). 

Solution  of  Lead  Suhacetate;  Liquor  Plumhi  Suhacetatis,  U.  S. 
P.;  Liquor  Plumhi  Suhacetatis  Fortis,  B.  P.;  Goulard's  Extract. 
It  is  an  aqueous  solution,  containing  about  25  per  cent  of  lead 
subacetate.    It  is  usually  employed  in  the  form  of  lead  water. 

Diluted  Solution  of  Lead  Subacetate;  Liquor  Plumbi  Suhaceta- 
tis Dilutus,  U.  S.  P.,  B.  P. ;  Lead  Water;  Goulard's  Lotion.  It 
contains  about  7.5  parts  (3  parts,  B.  P.)  of  the  subacetate  in  1,000 
parts  of  water.  Lead  water  is  frequently  employed  as  an  external 
cooling  sedative  astringent  in  local  inflammation,  sprains,  bruises, 
etc. ;  it  is  applied  pure,  or,  following  an  old  custom,  in  combina- 
tion with  laudanum  in  the  proportions  of  1  ounce  of  tincture  of 
opium  to  1/2  piiit  of  lead  water.  The  opium  in  this  combination 
does  not  exercise  any  function  whatsoever. 

Zinc  Chlorid;  Zinci  Chloridum,  U.  S.  P.,  B.  P.;  ZnClg. 

Etymology. — Zinc  is  first  spoken  of  in  the  writings  of  Basilius 
Valentinus  and  Paracelsus  in  the  fifteenth  century,  without  men- 
tioning where  it  was  obtained.  The  later  medical  chemists  usually 
spoke  of  zinc  ores  in  general  as  "zinc." 

Synonyms. — Butter  of  zinc ;  chlorure  de  zinc,  F. ;  Chlorzink,  G. 

Source  and  Character. — It  is  the  product  of  the  interaction 
between  hydrochloric  acid  and  zinc.  It  occurs  as  a  white,  gran- 
ular powder  or  porcelain-like  masses,  or  molded  into  pencils ;  odor- 
less, and  of  such  intensely  caustic  properties  as  to  make  tasting 
dangerous  unless  the  salt  be  dissolved  in  much  water.  It  has  a 
strong  metallic,  astringent  taste,  is  very  deliquescent,  and  should 
be  kept  in  glass-stoppered  bottles.     It  is  soluble  in  0.4  parts  of 


204  PHARMACO-THERAPEUTICS 

water  and  very  soluble  in  alcohol,  glycerin,  and  ether,  and  its 
solutions  have  an  acid  reaction.  It  fuses  at  240°  F.  (115°  C.)  to 
a  clear  liquid.  It  is  incompatible  with  alkalies  and  their  car- 
bonates, with  lead  acetate,  silver  nitrate,  the  tannates,  and  lime 
water. 
Average  Dose, — 1/2  grain  (0.03  Gm.),  largely  diluted. 

Preparations. — 

Liquor  Zinci  Cliloridi,  U.  S.  P.,  B.  P.  Solution  of  zinc  chlorid 
(Burnett's  disinfecting  fluid).  It  contains  about  50  per  cent  of 
the  salt. 

Medical  Properties. — Caustic,  disinfectant,  and  astringent. 

Therapeutics. — In  its  local  action,  zinc  chlorid  resembles  close- 
ly the  salts  of  lead,  silver,  and  copper,  forming  albuminates  by  its 
chemic  union  with  the  tissue  fluids.  The  precipitated  albumin  is 
of  a  loose,  flocculent  nature.  Applied  in  substance,  it  quickly 
liquefies  and  penetrates  into  the  soft  tissues,  destroying  the  parts, 
which  is  usually  accompanied  by  severe  pain.  It  acts  as  a  power- 
ful and  penetrating  caustic.  As  a  stimulating  astringent,  it  is 
employed  in  aqueous  solutions,  either  alone  or  in  combination 
with  other  antiseptics,  and  as  a  component  of  mouth  washes  which 
are  to  be  continuously  used  it  should  be  limited  to  1 :3,000  of  the 
solution.  An  eight  per  cent  aqueous  solution  of  zinc  chlorid  forms 
a  most  suitable  caustic  for  the  local  treatment  of  the  various  types 
of  stomatitis,  aphtha?,  ulcers,  etc.  In  the  form  of  a  paste,  known 
as  Canquoin's  paste,  consisting  of  equal  parts  of  wheat  flour  and 
zinc  chlorid,  with  very  little  wmter,  it  is  directly  applied  to  car- 
cinomatous growths,  lupus,  etc.     It  is  seldom  given  internally. 

Zinc  chlorid  enjoys  quite  a  reputation  as  a  very  efficient  topical 
remedy  for  the  treatment  of  hypersensitive  dentin.  It  is  applied 
to  the  isolated  and  partially  dried  tooth  in  substance  or  in  a  con- 
centrated solution.  At  first  usually  severe  pain  is  experienced, 
which  soon  ceases,  leaving  a  superficially  anesthetized  surface.  It 
does  not  penetrate  the  dentin  very  deeply  unless  applied  in  ex- 
cess or  for  a  long  period.  Too  close  proximity  to  the  pulp  forbids 
its  use  for  the  above  purpose,  as  it  endangers  the  life  of  this  or- 
gan. Technically,  it  is  used  in  various  dental  cements  and  as  a 
soldering  flux  in  the  laboratory. 

Toxicology. — Internally,  zinc  chlorid  acts  as  a  corrosive  poison, 
somewhat  similar  to  mercuric  chlorid.     The  treatment  consists  in 


ASTRINGENTS  205 

eniesis,  which  is  usually  produced  by  the  salt  Itself,  and  in  demul- 
cent drinks — white  of  egg,  or  milk — and  stimulants. 

Caustic  Zinc  Chlorid  Solution. 

IJ     Zinci  chloridi  gr.  xl   (2.6  Gm.) 

Aquoe  ad  flS  j   (30  C.c.) 

M. 
Sig. :     Apply  to  the  ulcerated  surface. 

Zinc  Sulphate;  Zinci  Sulphas,  U.  S.  P.,  B.  P.;  ZnSO^+THjO. 

Synonyms. — White  vitriol;  vitriol  blanc,  F. ;  Weisser  Vitriol, 
Weisser  Galitzenstein,  G. 

Source  and  Character. — It  is  formed  by  the  interaction  of 
zinc  and  diluted  sulphuric  acid.  It  appears  in  colorless,  transpar- 
ent crystals,  without  odor,  and  has  an  astringent,  metallic  taste. 
It  is  soluble  in  0.6  parts  of  water,  3  parts  of  glycerin,  and  is  in- 
soluble in  alcohol. 

Average  Dose. — As  an  emetic,  15  grains  (1  Gm.),  dissolved  and 
well  diluted  with  .water. 

Medical  Properties. — Tonic,  astringent,  antiseptic,  and  emetic. 

Therapeutics. — Zinc  sulphate  is  principally  used  as  an  astrin- 
gent in  1/2  to  10  per  cent  solutions  in  ulcerated  conditions  of  the 
mouth.  It  is  much  weaker  in  its  action  than  zinc  chlorid.  By  its 
irritating  effect  on  the  mucous  membrane  of  the  stomach  it  acts 
in  larger  doses  as  a  direct  and  prompt  emetic. 

Astringent  Solution  for  the  Oral  Cavity. 

IJ     Zinc,  sulphat.  3  j    (4.0  Gm.) 

Glycerin.  fl3  ij   (8  C.c.) 

Aquae  rosse  ad  flS  ij    (60  C.c.) 

M. 

Sig.:     To  be  diluted  with  an  equal  amount  of  water  and 
used  as  a  mouth  wash. 

Zinc  Phenolsulphonate  ;  Zinci  Phenolsulphonas,  U.  S.  P. ; 
Zinci  Sulphocarbolas,  B.  P.;  Zn(C6H504S)2;  Zinc  Sulpho- 
carbolate. 

It  appears  in  colorless,  transparent  crystals,  and  is  soluble  in 
about  twice  its  weight  of  alcohol  or  water.  It  is  an  antiseptic, 
stimulant,  and  astringent.  Its  solutions  are  employed  for  similar 
purposes  as  those  of  zinc  sulphate  and  in  about  the  same  strength. 


206  PHARMACO-THERAPEUTICS 

Whitslar^  has  recently  advocated  a  10  per  cent  aqueous  solution  of 
this  salt  as  an  efficient  astringent  and  antiseptic  for  the  treatment 
of  pyorrhea;  he  injects  it  deeply  into  the  pockets.  V/hether  zinc 
phenolsulphonate  possesses  greater  advantages  than  the  other 
metallic  astringents  and  antiseptics  in  the  treatment  of  pyorrhea 
alveolaris  is  questionable. 

Zinc  Iodid;  Zinci  Iodidum;  Znlj. 

It  is  a  white  granular  powder,  odorless,  and  has  a  sharp  saline 
and  metallic  taste.  It  is  readily  soluble  in  water,  alcohol,  ether, 
and  glycerin.  The  salt  is  liable  to  spontaneous  decomposition, 
and,  as  it  is  also  very  deliquescent,  it  should  be  kept  in  glass- 
stoppered  bottles.  It  is  strongly  astringent,  and  on  account  of 
its  iodin  component  promotes  tissue  changes.  Talbot  praises 
the  value  of  zinc  iodid  in  the  form  of  a  glycerinated  solution  for 
the  treatment  of  inflammatory  conditions  of  the  gums  accom- 
panying pyorrhea!  disturbances.  Talbot's  solution  of  this  salt  (see 
page  264)  deserves  to  be  highly  recommended.  As  all  iodin 
preparations  ruin  ordinary  metallic  instruments,  they  are  best  ap- 
plied on  an  iridio-platinum  applicator  or  on  a  toothpick  wound 
with  cotton.  Younger 's  solution  of  zinc  iodid  is  a  more  complicated 
preparation  and  inferior  to  the  Talbot  solution. 

Bismuth  Subgallate;  Bismuthi  Subgallis,  U.  S.  P.;  Dermatol. 

An  amorphous  saffron-yellow  powder,  without  odor  and  taste, 
yielding  about  50  per  cent  of  bismuth  oxid.  It  is  insoluble  in 
water,  alcohol,  and  ether,  but  soluble  in  diluted  alkalies  and  acids. 
It  is  used  as  an  intestinal  astringent  and  antiseptic,  and  exter- 
nally as  a  dusting  powder  on  wound  surfaces,  etc.  Average  dose, 
4  grains  (0.25  Gm.). 

Bismuth  Subnitrate  ;  Bismuthi  Subnitratis,  U.  S.  P.,  B.  P. ; 
Magisterium  Bismuthi;  Bismuth  Oxynitrate. 

A  white  heavy  powder,  without  odor  and  taste,  and  yielding 
about  80  per  cent  of  pure  bismuth  oxid.  It  is  insoluble  in  water 
and  alcohol,  but  soluble  in  acids.  It  is  used  as  an  internal  anti- 
septic and  astringent,  and  externally  as  a  dusting  powder  on  wound 
surfaces,  etc.     The  insoluble  bismuth  salts  act  as  absorbents  on 


>  Whitslar:  Dental  Summary,  1907,  No.  8. 


ASTRINGENTS  207 

wound  secretions,  thus  rendering  the  surface  less  suitable  for  tlie 
growth  of  bacteria.  Bismuth  is  not  a  harmless  remedy  when  ap- 
plied for  a  prolonged  period,  and  several  eases  of  poisoning  have 
been  recorded  from  its  surgical  use.  Average  dose,  7^  grains 
(0.5  Gm.). 

Xeroform;  Bismuth  Tribromplienolate.  A  neutral,  yellow,  in- 
soluble powder,  without  odor  and  taste,  yielding  about  60  per  cent 
of  bismuth  oxid.  It  is  used  as  an  astringent  and  antiseptic  in  the 
form  of  dusting  powder,  and  is  recommended  as  a  substitute  for 
iodoform. 

Alumnol;  Aluminum  Betanaphthol  Dissulphonate. 

A  white  non-hygroscopic  powder  soluble  in  1.5  parts  of  water 
and  in  glycerin,  and  sparingly  soluble  in  alcohol.  Its  solution  ex- 
hibits a  bluish,  fluorescence ;  on  exposure  to  air  the  powder  darkens. 
It  is  used  as  an  external  antiseptic  and  astringent  in  l/^  to  3  per 
cent  solutions.    In  strong  solutions  (10  to  20  per  cent)  it  is  caustic. 

Zinc  Oxid  ;  Zinci  Oxidum,  U.  S.  P.,  B.  P. ;  ZnO. 

Synonyms. — Nihil  album,  lana  philosophica,  flowers  of  zinc; 
oxyde  de  zinc,  F. ;  Zinkoxyd,  Zinkblumen,  G. 

Source  and  Character. — Zinc  oxid  is  made  by  exposing  zinc 
carbonate  to  a  dull  red  heat,  or  from  metallic  zinc  by  combustion. 
It  is  an  amorphous  white  powder,  without  odor  and  taste.  It  is 
insoluble  in  water  and  alcohol;  it  gradually  absorbs  carbon  dioxid 
from  the  air. 

Average  Dose. — 4  grains  (0.25  Gm.). 

Medical  Properties. — Antispasmodic  and  astringent. 

Therapeutics. — Zinc  oxid  is  employed  as  an  exsiccant  on  ex- 
coriated surfaces  by  sprinkling  it  on  the  affected  part,  or  in  the 
form  of  an  ointment  (zinc  oxid,  1  part;  benzoinated  lard,  4  parts, 
U.  S.  P.).  It  is  much  used  as  a  cosmetic  in  the  form  of  face 
powder.    Internally  it  is  given  in  chorea,  epilepsy,  etc. 

Technical  Uses. — Zinc  oxid  forms  the  base  of  the  various  zinc 
cements  employed  in  dentistry.  At  present  the  oxychlorid,  the 
oxyphosphate,  and  the  oxysulphate  cements  are  utilized.  In  1856 
Sorel,  of  Paris,  introduced  a  method  for  preparing  stucco  work, 
"consisting  of  a  coating  of  zinc  oxid  overlaid  with  a  coating  of 
zinc  chlorid. "     The  inventor  suggests  its  employment  "to  stop 


208  PHARMACO-THERAPEUTICS 

hollow  teeth,  for  which  its  plasticity  and  subsequent  impenetra- 
bility to  the  moisture  of  the  mouth  rendered  it  particularly  ap- 
plicable." Sorel's  cement  consists  of  a  powder  (calcined  zinc 
oxid)  and  a  liquid,  which  is  a  concentrated  aqueous  solution  of 
zinc  chlorid.  The  addition  of  small  quantities  of  borax  lessens 
the  rapid  setting  of  the  cement.  The  oxychlorid  cement  is  not 
used  at  present  as  a  permanent  filling  material,  but  it  is  still 
lauded  by  many  practitioners  as  the  ideal  root  filling,  either  alone 
or  in  combination  with  gutta-percha  cones.  If  the  cement  is 
placed  in  too  close  proximity  to  the  pulp,  it  may  produce  persistent 
irritation,  or  even  death  of  this  organ. 

The  Kostaings,  father  and  son,  dentists  in  Dresden,  prepared  in 
1878  a  filling  material  known  as  Dentinagen,  consisting  essentially 
of  a  mixture  of  phosphoric  acid  with  zinc  oxid.  The  combination 
is  known  at  present  as  oxyphosphate  of  zinc  cement.  The  various 
zinc  oxyphosphate  cements  play  an  important  role  in  the  arma- 
mentarium of  the  dental  practitioner.  These  cements  consist 
principally  of  a  powder  (calcined  zinc  oxid)  and  a  syrupy  solu- 
tion of  orthophosphoric  acid, 

A  zinc  oxysulphate  cement,  better  known  as  Fletcher's  artifi- 
cial dentin,  has  proved  itself  to  be  a  valuable  agent  for  temporary 
filling  purposes.  It  is  essentially  a  mixture  of  calcined  zinc  oxid, 
calcined  zinc  sulphate,  gum  mastic,  and  a  fluid  consisting  of  a 
thin  gum  arable  solution.  The  mixture  attains  about  the  hard- 
ness of  hydrated  plaster  of  Paris.  This  cement  is  largely  used  for 
the  retention  of  medicinal  application  in  teeth,  and,  combined 
with  formaldehyd,  is  sold  under  various  euphonious  titles. 

Oxysulphate  of  Zinc  Cement   (Artificial  Dentin). 

POWDER. 

H,     Powdered  mastic  3  vijss  (30  Gm.) 

Calcined  zinc  oxid  3  C   (400  Gm.) 

Calcined  zinc  sulphate  3  xij   (48  Gm.) 

LIQUID. 

R     Gum  arable  3  xxv   (100  Gm.) 

Water  fl3  Ixv  (260  C.c.) 

Alcohol  fl3  X  (40  C.c.) 

Liquid  phenol  Til.  xv   (15  drops) 


ASTRINGENTS  209 

Zinc  Acetate;  Zinci  Acetas,  U.  S.  P.,  B.  P.; 
Zn(C2H303),+2H20. 

It  is  a  white  crystalline  powder  or  plates,  soluble  in  21/2  parts 
of  water  and  36  parts  of  alcohol.  It  is  astringent  and  antiseptic, 
and  is  employed  in  y^  per  cent  solutions. 

Zinc  Sozo-Iodolate;  Zinc  Sozo-Iodolas.  It  appears  in  colorless 
needles,  which  are  soluble  in  25  parts  of  water,  in  alcohol,  and 
in  glycerin.  It  is  antiseptic  and  astringent,  and  is  employed  in 
14  to  2  per  cent  solutions. 

Zineol.  It  is  a  mixture  of  1  part  of  zinc  acetate  and  4  parts  of 
alumnol  (aluminum  beta-naphtoldisulfonate) ;  it  is  a  colorless  and 
odorless  powder,  which  dissolves  freely  in  water.  It  is  a  non- 
irritating  antiseptic  and  astringent,  and  is  employed  in  14  Psr  cent 
solution. 

Vegetable  Astringents. 

Tannic  Acid;  Acidum  Tannicum,  U.  S.  P.,  B.  P.;  HC14II9O9. 

Synonyms. — Tannin,  gallo-tannic  or  digallic  acid;  acide  tan- 
nique,  Fr. ;  Gerbsaure,  G. 

Source  and  Character. — Tannic  acid  is  an  organic  acid  ob- 
tained from  nutgall.  Nutgall  is  an  excrescence  on  the  oak  tree, 
Quercus  Lusitanica,  caused  by  the  puncture  of  and  deposited  ova 
of  an  insect,  Cynips  Gallce  Tinctorifs.  It  is  a  light-yellow,  amor- 
phous bulky  powder  or  spongy  mass,  with  a  slight  odor  and  a  strong- 
ly astringent  taste.  It  is  soluble  in  1  part  water  or  glycerin,  0.6 
parts  alcohol,  very  soluble  in  hot  water  and  hot  alcohol.  With  al- 
bumin and  glue-like  substances  of  the  tissues  it  forms  definite  com- 
pounds (leather),  which  are  insoluble  in  water,  but  partially  soluble 
in  alkalies  and  certain  acids.  Its  astringent  action  is  manifested 
even  in  very  weak  solutions  (^/^o  Psr  cent).  It  is  incompatible 
with  the  metallic  salts,  w4th  the  iodin  compounds,  and  with  easily 
oxidizable  substances — as  the  permanganates,  chlorates,  etc. ;  with 
ferric  salts  it  forms  blue-black  or  green-black  reaction.  It  should 
be  preserved  in  amber-colored  bottles,  well  stoppered. 

Average  Dose. — 1^2  grains  (0.5  Gm.). 

Medical  Properties. — Astringent,  styptic,  and  antiseptic. 

Preparation. — Glyceritum  Acidi  Tannici;  Glycerite  of  Tannic 
Acid,  U.  S.  P.;  Glycerinum  Acid  Tannici  (B.  P.),  is  a  20  per  cent 
solution  of  tannic  acid  in  glycerin. 


210  PHARMACO-THERAPEUTICS 

Therapeutics. — Tannic  acid  acts  as  a  powerful  astringent,  ex- 
ercising its  function  on  vessels  and  tissue  fibers;  it  coagulates 
blood.  When  placed  on  the  oral  mucous  membrane,  a  coagulation 
of  the  superficial  layers  results,  which  causes  a  feeling  of  con- 
striction, dryness,  and  roughness  in  the  mouth.  By  its  combina- 
tion with  the  secretions  of  the  wound  it  forms  a  protective  film 
over  the  denuded  surfaces.  If  applied  in  concentrated  solution, 
it  irritates  and  may  act  even  as  a  caustic.  Tannic  acid  is  used  as 
an  astringent  gargle  in  catarrhal  conditions  of  the  pharynx  (1  to 
2  per  cent  solutions),  and  internally  in  disturbances  of  the  stomach 
and  the  intestines.  As  an  internal  astringent  in  diarrhea  and  dys- 
entery it  is  of  doubtful  value.  It  is  much  used  as  an  external 
astringent  and  styptic  in  powder  form  or  in  concentrated  solu- 
tion, preferably  as  the  glycerite  of  tannic  acid.  It  is  a  valuable 
agent  for  the  treatment  of  hyperemia  and  the  early  stages  of  in- 
flammation of  the  pulp,  and  for  such  purposes  it  is  usually  applied 
in  a  paste  form — tannic  acid  mixed  with  phenol  or  eugenol.  As  a 
tanning  agent  of  the  devitalized  pulp,  it  is  best  applied  in  the  form 
of  the  glycerite.  Care  should  be  exercised  in  the  use  of  tannic 
acid  in  the  treatment  of  teeth  as  it  may  cause  bluish-black  discolora- 
tion resulting  from  a  freshly  formed  iron  tannate.  The  pure  acid 
or  its  many  modifications — rhatany,  witch-hazel,  oak  bark,  etc. — 
are  largely  used  as  components  of  mouth  washes.  (See  Prepara- 
tions for  the  Mouth  and  Teeth.) 

Tannic  acid  is  frequently  employed  as  an  antidote  for  alka- 
loids when  these  poisons  are  taken  into  the  stomach.  It  readily 
precipitates  the  alkaloids,  forming  tannates,  which  should  be  re- 
moved from  the  stomach  wdth  emetics  or  the  stomach  pump.  Tea 
or  coffee  are  usually  available  for  such  purposes ;  they  contain  more 
or  less  sufficient  tannin  to  render  them  important  adjuncts  in 
emergency  treatment. 

Styptic  Dusting  Powder. 

IJ     Alum.  ust. 

Acid,  tannic.  aa  3  j   (4.0  Gm.) 

M. 
Sig. :     Styptic  dusting  powder. 

Gallic  Acid;  Acidum  Gallicum,  U.  S.  P.,  B.  P.  An  organic  acid, 
usually  prepared  from  tannic  acid.  It  has  no  astringent  effect, 
and  possesses  very  little  medicinal  value. 


ASTRINGENTS  211 

Quite  recently  a  large  number  of  synthetically  prepared  tannic 
acid  compounds  have  been  introduced  into  therapeutics,  especial- 
ly for  internal  administration.  The  principal  object  of  these  prep- 
arations has  been  to  overcome  the  disagreeable  taste  and  irritat- 
ing action  of  tannic  acid,  and  to  reach  the  upper  intestines  with- 
out being  decomposed  by  the  gastric  juice.  The  more  impor- 
tant ones  are: 

Tannalhin.  A  tannin  albuminate.  It  is  a  light-brown,  odor- 
less, and  tasteless  powder,  containing  about  50  per  cent  tannin.  It 
is  insoluble  in  water  and  in  the  gastric  juice.  It  is  used  as  an 
intestinal  astringent.    Average  dose,  10  grains  (0.6  Gm.). 

Tannoform.  A  condensation  product  of  formaldehyd  and  tan- 
nin. It  is  a  reddish  powder,  insoluble  in  water,  but  soluble  in 
alkaline  liquids.  It  is  applied  externally  as  an  antiseptic  astrin- 
gent. 

Many  other  combinations  of  tannin  with  organic  bodies  are 
known — as  tanocol,  a  tannin-gelatin  compound;  tannopin,  a 
hexamethylenamin-tannin ;  tanningen,  a  diacetyl-tannin  com- 
pound, etc. 

Witch-Hazel  Water;  Aqua  Hamamelidis;  Extractum  Hamameli- 
dis  Liquidum,  B.  P. ;  Liquid  Witch-Hazel  Extract.  Both  are  solu- 
tions of  the  active  principle  of  witch-hazel  bark  (especially  gallic 
and  hamamelo-tannic  acid)  in  very  diluted  alcohol.  They  are  fa- 
vorite and  pleasant  astringent  lotions  applied  by  the  laity  as  anti- 
phlogistic and  styptic  remedies  after  the  extraction  of  teeth,  for 
spongy  gums,  etc. 

Bhatany;  Krameria,  B.  P.  The  dried  roots  of  a  variety  of 
rhatany  plants.  Rhatany  contains  on  an  average  from  7  to  8  per 
cent  of  kramero-tannic  acid  and  some  red  coloring  matter.  It  is 
especially  to  be  recommended  as  an  oral  astringent  in  the  form  of  a 
diluted  tincture  (rhatany,  1  part;  diluted  alcohol,  5  parts). 

White  Oak  Bark;  Quercus,  U.  S.  P.  The  dried  bark  of  white 
oak.  It  contains  about  7  per  cent  of  querci-tannic  acid.  It  is 
usually  employed  as  an  astringent  and  styptic  in  the  form  of  an 
infusion  or  of  the  diluted  fluidextract.  As  an  astringent  for  the 
oral  cavity  it  is  much  favored  by  some  practitioners. 

Other  plants — as  sumach,  blackberry,  cranesbill,  logwood,  kino, 


212  PHARMACO-THERAPEUTICS 

catechu,  etc. — contain  variable  amounts  of  ill-defined  tannic  acid 
modifications,  but  are  rarely  used  in  dental  practice. 

CAUSTICS. 

Caustics  (I  burn),  sometimes  called  escharotics  (a  slough  or 
burn),  are  substances  which  destroy  living  tissue  by  virtue  of  their 
coarse  chemic  or  physical  action,  affecting  organized  as  well  as 
nonorganized  albumin.  The  older  medical  lexicographers  restricted 
the  term  escharotic  to  substances  which  produce  a  dry,  more  or  less 
insoluble,  protective  slough.  They  further  differentiated  between 
the  actual  cautery,  i.  e.,  the  application  of  the  red  hot  iron  and  the 
potential  cautery,  i.  e.,  an  agent,  like  silver  nitrate,  which  forms 
an  eschar  without  the  agency  of  actual  fire.  True  caustic  action 
manifests  itself  essentially  in  two  definite  processes: 

1.  It  produces  coarse  chemic  or  physical  chajiges  in  the  tissue. 
These  changes  are  macroscopically  recognizable. 

2.  It  causes  the  more  or  less  direct  death  of  those  affected 
tissues. 

Pure  chemic  drug  action  on  living  cell  structure  which  endan- 
gers, or  even  kills,  the  cell  without  visible  changes  is  referred  to  as 
protoplasm  poisoning,  while  a  drug  which  produces  severe  visible 
tissue  changes,  but  without  cell  destruction,  is  spoken  of  as  an 
irritant. 

Caustic  action  means  destruction  of  protoplasm.  It  may  be 
produced : 

1.  By  abstracting  water  from  albumin.  The  normal  quantity 
of  water  present  in  the  living  cell  amounts  to  75  to  90  per  cent.  If 
a  more  or  less  greater  amount  of  this  water  is  removed,  the  cell 
will  die.  The  neutral  salts,  glycerin,  etc.,  are  chemicals  which 
produce  such  an  effect.  (If  sodium  chlorid  is  taken  in  large 
quantities  into  the  empty  stomach,  it  may  produce  severe  cauteri- 
zation of  the  stomach  wall,  or  even  death.)  Substances  which 
act  only  by  virtue  of  their  affinity  for  water  are  not  employed  as 
caustics  in  medical  practice. 

2.  By  dissolution  of  albumin.  Alkalies  and  caustic  alkalies  are 
albumin  solvents.  The  saturated  alkaline  salts — potassium  or 
sodium  carbonate^are  mild  caustics,  while  potassium  or  sodium 
hydrate,  which  contain  free  hydroxyl  groups,  are  very  powerful 


CAUSTICS  213 

in  their  action.  The  caustic  alkalies  are  not  self-limiting;  they 
penetrate  deeply  into  the  tissues,  and  destroy  the  albumin  of  the 
mucous  surfaces,  the  horny  tissues,  and  the  external  skin.  The 
lower  fatty  acids  act  also  as  solvents  of  albumin. 

3.  By  precipitation  of  albumin.  Agents  acting  as  albumin  pre- 
cipitants  are:  (a)  Many  acids — all  inorganic  acids,  except  phos- 
phoric acid;  the  chlorin  substituted  fatty  (organic)  acids,  and 
those  aromatic  acids  which  are  readily  soluble  in  water  to  such  an 
extent  as  to  produce  the  desired  effect — tannic  acid ;  the  resultant 
acid-albumin  is  known  as  syntonin.  (b)  Solutions  of  metallic  oxids 
and  their  salts;  they  act  as  precipitants  of  albumin  through  their 
acid  as  well  as  through  their  basic  components;  the  precipitate 
produced  by  the  metallic  salts  differs  widely  in  regard  to  its  dens- 
ity— ^silver  nitrate,  for  instance,  produces  a  dry,  dense  scab,  while 
zinc  chlorid  combines  with  the  albumin  to  form  a  loose,  flocculent 
clot,  (c)  Certain  organic  compounds — as  phenol,  trinitrophenol 
(picric  acid),  and  alcohol;  the  latter  precipitates  albumin  only 
when  applied  in  solutions  containing  at  least  65  per  cent  or  more 
of  pure  alcohol. 

4.  By  oxidation.  The  strong  oxidizing  agents,  like  nitrous  acid, 
sulphurous  acid,  and  chromic  acid  (chromium  trioxid),  disinte- 
grate albumin,  as  well  as  many  other  organic  and  inorganic  sub- 
stances; they  completely  destroy  the  albumin  molecule. 

5.  By  substitution.  lodin,  bromin,  and  chlorin  act  on  the  al- 
bumin molecule  by  substitution — that  is,  atoms  of  hydrogen  are 
replaced  by  atoms  of  the  whole  halogen,  which  destroy  the  life  of 
the  cell;  at  the  same  time  halogen  acids  are  formed,  which  act  as 
precipitants  of  albumin. 

In  general,  caustics  are  more  or  less  related  to  antiseptics, 
astringents,  styptics,  and  irritants.  The  tissues  involved  by  their 
application  are  always  superficially  destroyed.  Certain  caustics 
(potassium  hydrate)  act  on  the  deeper  structures.  The  vessels 
within  the  area  of  the  applied  caustic  become  thrombosed,  and 
the  blood  corpuscles  disintegrate.  A  reactive  inflammation  is  set 
up  within  the  region  of  the  applied  caustic,  which  in  due  time  re- 
moves the  scab  formed  by  the  latter. 

Caustics  are  employed  for  the  purpose  of  destroying  living  or 
dead  tissue.    Besides  chemicals,  the  knife,  the  actual  cautery,  either 


214  PH  ARM  A  CO-THERAPEUTICS 

in  the  form  of  the  electric  cautery  or    the    old-fashioned    ferrum 
candens,  or  electric  destruction  is  used. 
Caustics  are  indicated: 

1.  To  destroy  specific  poisons.  For  the  treatment  of  fresh  in- 
fections on  external  surfaces  resultant  from  the  bite  of  a  poisonous 
snake  or  a  scorpion,  or  all  such  accidents  which  inoculate  the  wound 
with  a  nonbacterial  or  specific  poison,  potassium  permanganate  in 
concentrated  solution  is  highly  recommended. 

2.  To  destroy  hacterial  infection.  Local  infection  resultant 
from  the  bite  of  a  vicious  dog  (hydrophobia),  or  from  an  anthrax 
carbuncle,  or  a  chancre,  etc.,  is  destroyed  by  the  application  of 
lactic  acid,  or,  in  severe  cases,  of  chromic  acid,  or  caustic  potash; 
the  latter  has  a  pronounced  deep  action. 

3.  To  destroy  tumors,  neoplasms,  and  normal  or  abnormal  tis- 
sue. Polypi,  epulis,  small  aneurysms,  hypertrophied  mucous  mem- 
brane or  gum  tissue,  and  intense  granulation  in  a  wound  (proud 
flesh)  are  destroyed  or  checked  by  the  application  of  solutions  of 
trichloracetic  acid  in  various  strengths.  To  destroy  the  tooth 
pulp,  arsenous  acid  (arsenic  trioxid)  is  the  remedy  par  excellence. 

4.  To  inJiihit  tlie  progress  of  dental  caries.  Silver  nitrate, 
continuously  applied  in  substance  or  in  concentrated  solution  until 
the  silver  has  been  reduced  to  a  jet  black  oxid  by  the  action  of 
sunlight,  will  absolutely  inhibit  the  progress  of  dental  caries. 

5.  To  keep  fistulas  open,  or  to  destroy  tlieir  epithelial  lining. 
Liquid  phenol,  follow^ed  by  alcohol,  deserves  to  be  recommended 
for  such  purposes. 

The  application  of  caustics  is  usually  accompanied  by  severe 
pain,  which,  to  some  extent,  may  be  mitigated  by  the  previous  ap- 
plication of  local  anesthetics.  The  destruction  of  a  large  area  of 
tissue  is  usually  followed  by  the  formation  of  a  more  or  less  ex- 
tensive cicatrix,  and  extreme  care  should  therefore  be  exercised 
in  the  use  of  caustics. 

Liquid  Caustics. 

Trichloracetic  Acid;  Acidum  Trichloraceticum,  U.  S.  P.; 

HC2CI3O2. 

It  forms  white  deliquescent  crystals,  having  a  pungent,  char- 
acteristic odor.    It  is  readily  soluble  in  w^ater,  alcohol,  and  ether. 


CAUSTICS  215 

A  50  per  cent  aqueous  solution  is  known  as  acetocaustin.  It  is  a 
powerful  caustic  and  astringent.  In  50  per  cent  solution  it  is  used 
to  destroy  polypi,  epulitic  growths,  gum  tissue,  etc.  In  5  to 
10  per  cent  solution,  either  alone  or  in  combination  with  otlier 
drugs,  it  is  employed  for  the  treatment  of  alveolar  pyorrhea.  It 
should  be  applied  with  a  glass  rod  or  on  a  looped  platinum  wire. 

Lactic  Acid  ;  Acidum  Lacticum,  U.  S.  P.,  B.  P. ;  CaH^O;,. 

A  colorless  liquid  organic  acid,  containing  75  per  cent  of  pure 
lactic  acid.  It  is  freely  miscible  with  water,  alcohol,  and  ether, 
but  insoluble  in  chloroform.  It  has  a  pronounced  sour  taste.  In 
its  pure  form  it  is  used  as  a  caustic  swab  on  the  patches  of  leuco- 
plakia  and  in  pyorrhea  pockets. 

Solution  of  Sodium  Ethylate;  Liquor  Sodii  Ethylatis,  B.  P. 

An  18  per  cent  solution  of  sodium  ethylate  in  absolute  alcohol. 
A  colorless,  syrupy  liquid,  which  decomposes  in  the  presence  of 
water;  it  should  be  recently  prepared.  It  is  a  mild  caustic,  which 
does  not  penetrate  deeply  into  the  tissues. 

Nitric  Acid;  Acidum  Nitricum,  U.  S.  P.,  B.  P.;  UNO.,. 

A  colorless  fuming  fluid,  containing  about  68  per  cent  of  abso- 
lute nitric  acid,  and  has  a  suffocating  odor.  It  is  very  caustic 
and  corrosive,  staining  woolen  fabrics  and  animal  tissues  a  bright 
yellow — xanthoprotein.     It  should  be  handled  with  great  care. 

Liquid  phenol,  sometimes  creosote,  and,  to  a  still  less  extent, 
cresol,  are  quite  frequently  used  as  caustics.  As  these  agents 
are  very  readily  soluble  in  alcohol,  their  action  on  the  tissues  is 
limited  by  following  their  application  with  a  swab  of  pure  alcohol. 

Dry  Caustics. 

Potassium  Hydroxid;  Potash  Hydroxidum,    U.    S.    P.;  Potassa 
Caustica,  B.  p.  ;  KOH ;  Caustic  Potash. 

Dry  white,  fused  masses,  or  in  pencils,  having  a  faint  odor  of 
lye  and  a  very  acrid  caustic  taste.  It  readily  absorbs  moisture 
and  deliquesces.  It  is  soluble  in  0.4  parts  of  water  and  in  2  parts 
of  alcohol. 

Solution  of  Potassium  Hydroxid;  Liquor  Potassii  Hydroxidi, 


216  PHARMACO-THERAPEUTICS 

U.  S.  P. ;  Liquor  Potassce,  B.  P.     An  aqueous  solution  of  potas- 
sium hj^droxid,  containing  about  5  per  cent  of  the  salt. 

Sodium  Hydroxid;  Sodii  Hydroxidum,  U.  S.  P.;  NaOH 
Caustic  Soda. 

White,  transparent  pencils,  which  are  deliquescent  in  the  air 
and  very  caustic. 

Solution  of  Sodium  Hydroxid;  Liquor  Sodii  Hydroxidi,  U.  S.  P. 
An  aqueous  solution  of  sodium  hj'droxid,  containing  about  5  per 
cent  of  the  salt. 

Robinson's  Remedy. 

IJ     Phenolis  crystal. 

Potassii  hydroxidi  aa  3  j    (4.0  Gm.) 

M. 

Sig. :  Mix  by  trirurating  in  a  heated  mortar  until  a  crystal- 
line paste  is  formed.  (The  addition  of  a  few  drops  of 
glycerin  improves  the  mixture.) 

Schreier's  Alloy  of  Potassium  and  Sodium  ( Kalium-N atrium) . 
An  alloy  of  metallic  potassium  and  sodium  kept  in  a  bottle  tight- 
ly sealed  with  a  thick  layer  of  paraffin.  To  remove  the  prepara- 
tion, a  barbed  nerve  broach  is  pushed  through  the  paraffin  stop- 
per.   Handle  with  care ! 

Osmium  Tetroxid;  Acidum    Osmium;  OSO4;  Osmic  Acid. 

Yellowish  crystals,  having  a  very  pungent  odor;  readily  soluble 
in  water,  alcohol,  and  ether.  It  is  a  very  powerful  caustic,  and 
its  vapors  are  exceedingly  irritating  to  the  air  passages  and  the 
eyes.  Osmic  acid  has  a  special  affinity  for  fatty  and  nerve  sub- 
stance, and  is  therefore  recommended  in  the  form  of  an  injection 
in  1/20  to  1/6-grain  (0.003  to  0.01  Gm.)  doses  several  times  a  day 
as  a  1  per  cent  solution  (consisting  of  60  parts  of  water  and  40 
parts  glycerin)  in  trigeminal  neuralgia  as  a  means  of  destroying 
the  sensory  nerve  tissue.  As  osmic  acid,  by  reduction,  produces  a 
black  stain,  it  may  permanently  discolor  the  face. 

Chromium    Trioxid;    Chromii    Trioxidum,    U.    S.    P.;    Acidum 
Chromicum,  B.  p.;  CrOa;  Chromic  Acid;  Chromic  Anhydrid. 

It  forms  small  crystals  of  a  purplish-red  color  and  a  metallic 
luster;  is  odorless,  and  destructive  to  animal  and  vegetable  tissues. 


CAUSTICS  217 

It  is  deliquescent  in  moist  air,  and  very  soluble  in  water.  When 
brought  in  contact  with  organic  substances — as  cork,  tannic  acid, 
sugar,  alcohol,  collodion,  glycerin,  etc. — decomposition  takes  place, 
and  sometimes  with  dangerous  violence. 

Solution  of  Cliromic  Acid;  Liquor  Acidi  CJiromii,  B.  P.  An 
aqueous  solution  of  chromium  trioxid  in  water,  containing  about 
29  per  cent  of  the  anhydrid. 

Barium  Sulphid;  Baku  Sulphidum;  BaS. 

A  yellowish-green,  amorphous  and  phosphorescent  powder  or 
lumps,  having  a  pronounced  odor  of  hydrogen  sulphid.  It  is 
employed  as  a  convenient  and  comparatively  harmless  means  of 
removing  hair  from  body  surfaces  in  the  form  of  a  delipatory 
paste. 

Depilatory  Paste. 

B     Barii  sulphidi  3  j    (4.0  Gm.) 

Amyli  3  iij    (12.0  Gm.) 

M. 

Sig. :  Mix  with  water  to  a  creamy  paste,  and  apply  thickly 
with  a  wooden  spatula  over  the  hairy  surface.  In  a  few 
minutes  it  should  be  washed  off  and  a  bland  ointment  applied. 
The  paste  should  be  freshly  prepared. 

Silver  Nitrate  ;  Argenti  Nitras,  U.  S.  P.,  B.  P. ;  AgNOg. 

Etymology. — The  word  silver  is  derived  from  the  old  English 
selver  or  the  Anglo-Saxon  seolfor.  The  Latin  argentum  and  the 
Greek  argyros  are  derived  from  the  same  root,  argos,  meaning 
white,  while  the  Hebrew  term  kesepJi  is  derived  from  a  root  mean- 
ing pale.  The  alchemists  termed  silver  luna  or  diana.  Geber, 
the  celebrated  Arabian  alchemist  of  the  eighth  century,  is  the 
first  writer  who  refers  to  a  formula  for  making  crystalline  silver 
nitrate,  and  Augustus  Sala,  at  the  end  of  the  seventeeth  century, 
called  the  attention  of  the  medical  chemists  to  this  salt,  which 
he  named  crystalli  diance  or  magisterium  argenti,  from  which, 
by  melting,  he  obtained  the  lapis  infernalis. 

Synonyms. — Lunar  caustic,  lapis  infernalis;  pierre  infernale, 
F. ;  Hollenstein,  G. 

Source  and  Character. — Silver  nitrate  is  usually  prepared  by 
dissolving  pure  silver  in  diluted  nitric  acid  and  set  aside  for 
crystallization.  "It  is  a  colorless  and  transparent  tubular,  rhom- 
bic crystalline  salt,  becoming  gray  or  grayish-black  on  exposure 


218  PHARMACO-THERAPEUTICS 

to  light  in  the  presence  of  organic  matter;  odorless,  having  a  bit- 
ter, caustic,  and  strongly  metallic  taste  and  a  neutral  reaction; 
soluble  at  77°  F.  (25°  C.)  in  0.54  parts  of  water  and  24  parts  of 
alcohol,  and  in  0.1  part  of  boiling  water  and  5  parts  of  boiling 
alcohol.  When  heated  to  about  392°  F.  (200°  C.)  the  salt  melts, 
forming  a  faintly  yellow  liquid,  which,  on  cooling,  congeals  to  a 
pure  white  crystalline  mass.  At  a  higher  temperature  it  is  grad- 
ually decomposed  with  the  evolution  of  nitrous  vapors.  It  should 
be  kept  in  dark-colored  vials,  protected  from  light." 

The  solution  stains  the  skin  an  indelible  black,  and  it  is  itself 
discolored  by  the  most  minute  portions  of  organic  matter,  for 
which  it  forms  a  delicate  test.  The  solution  also  stains  linen  and 
muslin  fibers,  and  exposure  to  sunlight  hastens  this  process.  To 
remove  the  stains,  a  solution  of  sodium  hyposulphite,  potassium 
cj^anid,  or  ammonium  chlorid  may  be  readily  employed.  It  is 
incompatible  with  ordinary  water  on  account  of  the  sodium  chlorid 
which  it  contains,  with  soluble  chlorids  in  general,  with  the  min- 
eral acids,  with  alkalies  and  their  carbonates,  with  lime  Avater,  and 
with  astringent  infusions. 

Average  Dose. — %  grain  (0.01  Gm.). 

Preparations. — 

Argenti  Nitras  Fusus;  Molded  Silver  Nitrate  or  Lutiar  Caustic, 
U.  S.  P.  It  is  prepared  by  melting  100  grams  of  silver  nitrate  with 
4  grams  of  hydrochloric  acid  and  poured  into  suitable  molds.  The 
British  Pharmacopeia  prepares  a  toughened  caustic,  argenti  nitras 
induratus,  by  adding  5  parts  of  potassium  nitrate  to  95  parts  of 
silver  nitrate. 

Argenti  Nitras  Mitigatus;  Mitigated  Caustic.  It  is  prepared  by 
melting  30  grams  of  silver  nitrate  with  60  grams  of  potassium  ni- 
trate and  cast  into  suitable  molds. 

Medical  Properties. — Antiseptic,  astringent,  caustic,  and 
hemostatic. 

Local  and  General  Action. — When  solid  silver  nitrate  is 
brought  in  contact  with  living  tissue,  a  deep  staining  of  the  super- 
ficial layer  is  produced  as  a  result  of  the  reduction  of  the  silver, 
followed  by  acute  pain  and  partial  inflammation  of  the  deeper 
structures,  resulting  in  destruction  of  the  upper  layers,  which 
finally  separate  as  a  slough ;  the  corroded  surfaces  heal  quickly. 
On  the  mucous  membranes  or  the  broken  skin  it  acts  much  like 
lead  salts,  but  more  powerful,  while  it  is  less  active  than  the 


CAUSTICS  219 

mercury  salts.  It  readily  precipitates  albumins  and  chlorids  from 
the  plasma  or  the  serumnal  discharge ;  in  weak  solutions  it  actively 
contracts  arteries  and  veins.  The  formation  of  a  protective  layer 
of  coagulated  albumin  limits  its  penetration  into  the  deeper  struc- 
tures and  reduces  its  action  to  an  astringent.  The  precipitation 
of  albumin  is  fairly  recognizable  in  14  per  cent  solution — it  in- 
creases with  the  density  of  the  latter;  a  10  per  cent  solution  pro- 
duces a  firm  coagulum.  By  its  controlling  influence  on  the  vascu- 
lar disturbances,  the  exudations,  and  the  growth  of  the  inflamma- 
tory area,  it  acts  as  an  antiphlogistic.  In  solid  form  it  is  employed 
as  a  hemostatic.  Silver  nitrate  is  the  most  powerful  caustic  and 
astringent  of  all  the  metallic  salts  which  can  be  applied  with 
safety.  Locally  it  does  not  produce  toxic  effects  or  dangerous  in- 
flammatory disturbances,  as  its  action  is  distinctly  self-limiting. 
Given  internally  for  a  longer  period,  or  even  from  the  prolonged 
use  of  silver  solution  by  external  application  on  mucous  surfaces 
or  denuded  skin,  the  silver  is  quite  often  absorbed  by  the  system 
(although  most  of  it  is  changed  to  the  insoluble  silver  chlorid), 
and  permanently  stains  the  body  surfaces  by  forming  dense  gran- 
ules in  the  connective  tissue,  thus  giving  the  skin  and  mucous 
membrane  an  unsightly  dark-brown  appearance,  known  as  argyria. 
The  pigmentation  was  more  common  in  earlier  years  than  at 
present,  owing  to  its  restricted  internal  use. 

Specific  Application  in  Dentistry. — As  early  as  1846  we  read 
in  the  "Zahnarzt"  that  the  application  of  silver  nitrate  to  ca- 
rious surfaces  on  teeth  is  very  beneficial,  as  it  "practically  stops 
the  progress  of  the  carious  process."  Brooks,^  in  1854,  calls  at- 
tention to  the  value  of  this  chemical  in  the  treatment  of  erosion, 
saying  that  "it  does  discolor  the  cavity,  but  it  prevents  further 
progress."  A  number  of  prominent  practitioners — as  Clark, 
Chupein,  Shanasy,  Tomes,  Salter,  Bauer,  Black,  Miller,  Pierce, 
Conrad,  and  many  others — have  greatly  lauded  the  value  of  silver 
nitrate  as  a  means  of  abating  the  progress  of  dental  caries,  and 
especially  Taft,^  as  early  as  1859,  expresses  himself  most  favor- 
ably on  this  subject. 

"The  compound  formed  by  the  nitrate  with  the  organic  con- 
stituents of  the  tooth  is  insoluble,  except  with  a  few  substances, 
and  therefore  protects  the  subjacent  parts,  and  the  precipitation 


*  Brooks:  American  Journal  of  Dental  Science,  Vol.  III. 
'Taft:  Operative  Dentistry,  1859,  p.  214. 


220  PHARMACO-THERAPEUTICS 

of  the  reduced  oxid  on  the  surface  affords  some  additional  pro- 
tection. The  insolubility  of  the  compound  mentioned  prevents  an 
absorption  of  the  nitrate  by  the  dentin,  and  renders  its  action 
necessarily  superficial.  When  the  nitrate  is  neutralized  by  a 
union  with  it  of  an  equivalent  of  the  constituents  of  the  dentin, 
no  further  chemical  action  is  possible.  It  is  quite  evident  that 
no  harm  can  result  to  the  tooth  from  proper  application  of  this 
agent  beyond  the  portion  of  it  immediately  acted  upon.  The 
nitrate  can  be  absorbed  by  the  dentin,  but  it  stimulates  the  sub- 
jacent dentin  to  more  healthy  action." 


Fig.  34. 
Silver  nitrate  applied  to  carious  dentin.     Low  power.     (After  Szabo.) 

Silver  nitrate  applied  to  sound  teeth  as  a  so-called  prophylactic 
measure — that  is,  a  means  of  preventing  dental  caries — is  freely 
indorsed  in  recent  dental  literature.  On  sound  enamel  argentic 
nitrate  has  very  little  effect,  while  on  cracked  enamel,  or  on  en- 
amel of  a  tooth  with  a  destroyed  pulp  (on  account  of  the  ab- 
sence of  moisture)  the  silver  salt  has  a  better  chance  to  reach 
the  intercellular  cement  substance. 

In  "the  course  of  human  events"  many  of  the  pertinent  clini- 
cal observations  of  the  older  writers  have  escaped  recent  investi- 
gators, and  many  contradictory  theories  have  been  promulgated 


CAUSTICS 


221 


regarding  the  action  of  silver  nitrate  on  dentin.  The  late  Harlan^ 
has  claimed  that  "when  solutions  of  silver  nitrate  were  used  it 
was  found  not  to  penetrate  the  tubules  to  any  extent,  and  it  was 
classed  as  self-limiting  with  other  coagulants.  The  silver  nitrate 
furnishes  its  own  stain,  and  the  degree  of  penetration  was  easily 
defined  in  sections  of  the  root."  James  Truman,^  on  the  other 
hand,  relates  from  his  experiments:  "The  action  of  nitrate  of 
silver  in  repeated  tests  was  rather  a  surprise.  It  has  generally 
been  regarded  as  a  superficial  coagulant,  but  in  every  instance 
has   proved   deeply   penetrating,    and    coagulating    with    rapidity 


Fig.  35. 

Silver  nitrate  applied  to  carious  dentin.     High  power.     (After  Szabo.) 

and  certainty — very  nearly  equal  to  zinc  chlorid."  The  forego- 
ing diametrically  opposed  versions  of  the  two  investigators  are 
due  to  the  fact  that  their  research  work  was  conducted  on  teeth 
out  of  the  mouth  and  in  test  tubes.  Even  taking  for  granted  that 
physical  and  cheraic  conditions  could  be  established  relatively 
equal  to  those  in  the  mouth,  there  are  other  processes  concerned 
in  the  maintenance  of  living  tissue  which  can  not,  for  the  pres- 
ent at  least,  be  supplements  in  the  laboratory.    Conclusions  drawn 


'Harlan:  Dental  Cosmos,  1898,  p.  287. 
'Truman:  Dental  Cosmos,  1895,  p.  1. 


222  PHARMACO-THERAPEUTICS 

from  such  experiments  are  often  misleading,  and  they  are  of  little 
practical  value.  The  first  systematic  investigation  of  the  action 
of  silver  nitrate  on  dentin  was  conducted  by  Szabo/  of  Arkovj^'s 
clinic  in  Budapest.  Szabo  approached  this  important  problem 
in  a  more  methodical  manner.  His  experiments  Avere  conducted 
on  the  teeth  in  the  living  subject.  The  lower  first  molars,  having 
central  cavities,  were  selected  for  his  experimental  work,  and  the 
silver  nitrate  applied  in  10,  20,  30  and  40  per  cent  solutions  and  in 
the  pure  powdered  state.  The  applications  were  repeated  in  some 
cases  up  to  twenty-five  times.  In  due  time  the  teeth  were  ex- 
tracted. After  decalcifying  and  fixing,  microscopic  sections  were 
prepared  and  the  following  phenomena  observed:  The  contents 
of  the  tubules  are,  up  to  a  certain  depth,  destroyed,  and  small 
concrements,  stained  deeply  black,  in  the  form  of  debris,  are  seen. 
This  debris  is  coagulated  albumin,  bacteria,  etc.,  resulting  from 
the  action  of  the  silver  nitrate,  which,  on  exposure  to  light,  as- 
sumes a  black  color.  The  dense  mass  of  coagulated  silver-albumin 
checks  the  further  action  of  silver  nitrate.  The  penetration  of 
the  silver  salts  into  the  diseased  dentin  is  limited  to  about  ^o  of 
an  inch;  a  further  penetration  could  not  be  observed,  no  matter 
how  strong  and  how  often  the  application  was  renewed.  On 
sound  dentin  the  penetration  was  very  superficial  indeed.  That 
part  of  the  dentinal  fibrils  which  comes  in  direct  contact  with  the 
silver  salt  is  destroyed  by  coagulation,  changing  the  semiliquid 
protoplasmic  contents  of  the  tubules  into  a  solid  mass  of  silver- 
albumin,  which,  on  exposure  to  light,  becomes  black  and  insoluble. 
Beyond  this  line  of  demarcation  the  dentinal  fibrils  are  not  al- 
tered, but  preserve  their  normal  appearance.  The  action  of  sil- 
ver nitrate  on  an  albumin  solution  in  vitro  produces  a  dense  sil- 
ver-albumin, which  in  every  respect  corresponds  microscopically 
to  the  above  described  precipitated  contents  of  the  dentinal 
tubules.  From  the  foregoing  facts  we  are  forced  to  conclude  that 
silver  nitrate  possesses  a  comparatively  limited  power  of  penetra- 
tion into  dentin ;  it  does  not  act  deeply  enough  to  endanger  the 
vitality  of  the  dentinal  fibrils,  a  conception  which  is  held  by  Walk- 
hoff,  Miller,  Szabo,  and  Preiswerck. 

Within  recent  years  Stebbins-  has   strongly  emphasized  the 
value  of  silver  nitrate  as  a  means  of  permanently  checking  the 


*  Szabo:  Osterreichisch-Ungarische  Vierteljahrsschrift  fur  Zahnheilkunde,  1902,  p.  42. 
'Stebbins:  International  Dental  Journal,  1891,  No.   10. 


CAUSTICS 


223 


progress  of  dental  caries  and  as  a  prophylactic  for  the  same  dis- 
ease, especially  in  children.  The  same  method  has  been  repeated- 
ly indorsed  by  Shanasy/  Frank,  Niles,^  and,  recently,  by  Bryan.^ 
Some  practitioners  have  even  gone  so  far  as  to  speak  of  "restor- 
ing the  softened  dentin"  by  employing  silver  nitrate  in  substance, 
in  concentrated  solution,  or  in  the  form  of  filling  materials.  The 
early  application  of  silver  nitrate  on  those  peculiar  denuded  tooth 
surfaces  known  as  erosion  is  also  much  lauded.  Shanasy,  Conrad, 
Preiswerck,  and  others  have  strongly  favored  such  treatment.     As 


Fig.  36. 

Action   of  silver  nitrate   on   dentinal   fibrils.      (After  Szabo.) 

a  means  of  destroying  the  dental  pulp,  it  has  been  employed  in 
the  very  early  days  of  conservative  dentistry,  even  many  years 
before  Spooner  introduced  arsenic  for  this  purpose  (1836).  On 
account  of  its  self-limited  action,  it  readily  gave  way  to  the 
promptly  acting  arsenic.  Bethel*  advocated  the  cataphoric  appli- 
cation of  silver  nitrate  for  the  sterilization  of  infected  root  canals. 
The  resultant  discoloration  of  the  tooth  structure  prevented  its 
general  acceptance  by  the  profession.    As  a  means  of  relieving  the 


^Shanasy:  Dental  Cosmos,  1898,  p.  876. 
^Niles:   I^'Odontologie,  1900,  No.  8. 
'Bryan:  Dental  Review,  1903,  No.  7. 
♦Bethel:  Ohio  Dental  Journal,  1896,  No.  9. 


224  PHARMACO-THERAPEUTICS 

hypersensitiveness  of  dentin  it  is  much  praised  by  some  practition- 
ers, wliile  others  claim  that  it  is  very  uncertain  in  its  action.  The 
black  discoloration  prohibits  its  use  for  such  purposes  on  the  an- 
terior teeth.  For  the  cauterization  of  aphthous  growths  in  the 
oral  cavity,  the  destruction  of  hypertrophic  gum  tissue  and  small 
tumors,  and  for  similar  purposes,  it  is  frequently  recommended. 
As  a  stimulating  astringent  and  antiseptic,  applied  in  various  dilu- 
tions for  the  treatment  of  suppurative  processes  of  the  antrum 
and  for  so-called  * '  dry  sockets, ' '  it  deserves  praise.  Cravens  lauds 
it  as  the  ideal  medicinal  application  in  the  treatment  of  pyorrhea. 
Careful  clinical  observations  have  unquestionably  proved  that 


Fig.  37. 

Action  of  silver  nitrate  on  living  dentin.     Cervical  cavity.     (After  Szabo.) 

the  thorough  impregnation  of  a  carious  defect  with  silver  nitrate 
checks  the  further  progress  of  this  disease.  Preiswerck^  explains 
this  phenomenon  as  follows:  The  favorable  action  of  argentic  ni- 
trate on  the  course  of  caries  may  be  explained  by  the  insoluble 
combinations  which  it  forms  with  the  organic  tooth  substance, 
and  thus  withdrawing  the  nourishment  from  the  bacteria.  We 
may  assume  that  the  chemic  process  consists  in  the  coagulation 
of  the  albumin  and  the  formation  of  the  albuminate  of  silver  oxid. 
Furthermore,  since  the  animal  tissues  always  contain  sodium 
chlorid,  a  chemic  change  occurs,  in  which  the  nitric  acid  of  the 


iPreiswerck:  Atlas  and  Text  Hook  of  Dentistry,  1906,  p.  219. 


CAUSTICS  225 

argentic  nitrate  combines  with  the  sodium  and  the  chlorin  com- 
bines with  the  silver  to  form  the  insoluble  silver  chlorid: 

AgN03+NaCl=AgCl+NaN03. 

Miller^  has  proved,  however,  that  this  newly  formed  insoluble 
silver  chlorid  does  not  resist  the  action  of  acids  in  any  marked 
degree,  but  that  it  is  the  solid  mass  of  precipitated  black  silver 
albuminate  which  acts  principally  as  the  resisting  force.  This 
explanation  corresponds  with  clinical  observations.  If  silver 
nitrate  is  placed  into  a  cavity  or  upon  tooth  structure  and 
immediately  covered  by  a  protective  layer  of  gutta-percha  or 
cement  its  action  is  completely  nullified;  only  a  lemon  yellow 
stain — xanthoprotein — results.  Carious  surfaces  treated  with 
silver  nitrate  which  have  not  turned  black  do  not  resist  the  prog- 
ress of  caries,  while  the  jet-black  surfaces  are  immune.  Hence 
the  significance  of  Black's-  dogmatic  postulate:  "Expose  the 
tooth  surface  treated  with  silver  nitrate  to  sunlight  for  ten  min- 
utes until  a  full  black  color  is  obtained."  The  many  offered  sub- 
stitutes for  silver  nitrate — silver  lactate  and  citrate,  or  the  col- 
loidal silver  and  the  organic  silver  compounds — are  of  little  prac- 
tical use  for  this  work. 

Therapeutics. — Silver  nitrate  enjoys  quite  a  reputation  as  a 
means  of  checking  dental  caries.  In  fact,  it  is  the  only  chemical 
known  so  far  which  inhibits  the  progress  of  this  disease.  Its  ap- 
plication is  of  special  significance  in  the  treatment  of  children's 
teeth.  The  various  methods  of  application  differ  but  little.  The 
tooth  is  dried  as  much  as  possible  and  the  softened  decay  is  re- 
moved. The  silver  nitrate  is  applied  in  powder  or  crystal  form, 
moistened  with  just  enough  water  to  form  a  solution,  and  left  in 
contact  from  five  to  ten  minutes.  The  stick  form  may  be  em- 
ployed for  the  same  purpose;  or  blotting  paper,  according  to 
Pierce,  or,  still  better,  asbestos  felt,  as  suggested  by  Kirk,  is  satur- 
ated with  a  highly  concentrated  solution  of  the  salt  and  sealed 
into  the  cavity.  Holmes  carries  the  powdered  nitrate  into  the 
cavity  on  softened  gutta-percha,  while  Dubois  prepares  a  special 
gutta-percha  according  to  this  formula: 

IJ     Gutta-percha  3  j   (4.0  Gm.) 

Zine  oxid  3  iv  (16.0  Gm.) 

Silver  nitrate  3  ss  (2.0  Gm.) 

»  Miller:  Dental  Cosmos,  190S,  p.  193. 
'Black:  Operative  Dentistry,  1908,  Vol.  I. 


226  PHARMACO-THERAPEUTICS 

Much  benefit  results  from  the  early  application  of  silver  nitrate 
on  those  peculiar  denuded  tooth  surfaces  known  as  erosion.  At 
present  we  are  not  justified  in  giving  a  definite  exposition  of  the 
etiology  of  erosion.  Clinical  experience  has,  however,  demon- 
strated the  fact  that  the  process  is  checked  by  the  silver  applica- 
tion. The  only  objection  is  the  deep-black  color  which  it  pro- 
duces on  decayed  tooth  structure.  Bolten^  advises  the  application 
of  the  silver  salt  in  paste  form  on  denuded  tooth  surfaces  in  the 
following  manner:  The  gritty  surface  of  a  thin  polishing  strip 
is  covered  with  the  silver  paste,  placed  about  the  tooth,  and  held 
in  position  by  a  thin  metal  clamp,  or  the  strip  is  covered  with  a 
thin  rubber  cement.     The  paste  is  composed  of: 

^     Argenti  nitratis  3  j    (4.0  Gm.) 

Vaselini  q.  s.  to  make  a  stiff  paste. 

Hypersensitive  dentin  resulting  from  carious  defects  or  from 
senile  atrophy  of  the  alveolar  process  is  much  benefited  by  the 
silver  application.     It  is  particularly  useful  for  the  treatment  of 


Fig.  38. 
Adjustable  silver  nitrate  pencil. 

exposed  roots,  which  are  frequently  the  source  of  severe  acute 
pain  as  a  result  of  the  irritation  brought  about  by  cold  or  hot 
fluids.  To  apply  the  silver,  the  soft  part  should  be  protected 
with  a  napkin,  and  the  dry  root  is  thoroughly  impregnated  with 
the  caustic  pencil  or  a  concentrated  solution.  This  treatment  may 
be  repeated  if  necessary.  For  the  treatment  of  pj'orrhea  pockets, 
Cravens  advocates  a  10  per  cent  solution  or  the  crystals  melted 
on  a  platinum  wire.  A  convenient  wa}'  for  applying  silver  nitrate 
on  the  otherwise  inaccessible  places  in  the  mouth  consists  in  melt- 
ing a  few  crystals  into  a  bead  on  an  iridio-platinum  wire;  the 
wire  may  be  bent  in  any  direction.     In  the  treatment  of  shallow 


'Bolten:  Berliner  Zahnarztlichc  Halbmonatsschrift,  1908,  p.   159. 


CAUSTICS  227 

cavities  or  in  cases  of  recession  of  gum  tissue,  the  silver  nitrate 
is  best  applied  in  concentrated  solutions.  Black  describes  his 
method  as  follows.  It  is  best  to  dry  the  softened  area  as  deeply 
as  possible  with  the  warm  air  blast.  Make  a  saturated  solution 
by  crushing  a  small  crystal  on  a  glass  slab  and  adding  a  single 
drop  of  water.  Apply  this  to  the  area  of  decay  with  the  thin  end 
of  an  orange  wood  stick  and  saturate  the  entire  area  thoroughly. 
If  possible,  expose  the  patient  to  the  direct  rays  of  the  sun  for 
ten  to  twenty  minutes,  and  for  inaccessible  places  reflecting  the 
light  by  the  mouth  mirror  will  be  of  some  service.  In  due  time 
an  intense  black  color  is  obtained. 

To  facilitate  the  quick  reduction  of  the  silver  nitrate,  without 
the  aid  of  sunlight,  Shanasy  advocates  a  reducing  solution  con- 
sisting of  formaldehyd  and  solution  of  potash.  He  applies  the 
silver  nitrate  in  the  following  way:  Asbestos  fiber  is  saturated 
with  a  very  strong  silver  nitrate  solution  in  distilled  water,  dried 
and  preserved  in  a  bottle.  In  using  this  fiber  it  is  drawn  first 
through  the  official  solution  of  formaldehyd  and  then  through  a 
solution  of  caustic  potash  (U.  S.  P.  or  B.  P.)  and  immediately  ap- 
plied to  the  tooth  and  dried  with  warm  air,  if  possible.  Aphthous 
growths,  small  tumors,  polypi,  or  hypertrophied  gum  tissues  are 
readily  destroyed  by  applying  the  silver  in  substance  or  in  con- 
centrated solution.  A  concentrated  sodium  chlorid  solution  should 
always  be  kept  on  hand  to  immediately  check  the  silver  applica- 
tion, if  necessary.  Extemporaneously,  silver  nitrate  may  be  pre- 
pared for  local  application  by  dipping  a  silver  wire  into  nitric 
acid. 

Toxicology. — Fatal  results  from  poisoning  with  silver  nitrate 
are  rare,  but  nevertheless  its  use  in  the  mouth  requires  caution. 
The  caustic  pencil  may  loosen  from  its  holder  and  slip  into  the 
larynx;  an  accident  of  this  nature  has  occurred  and  caused  the 
death  of  a  child.  Common  salt  or  ammonium  chlorid  are  its 
chemic  antidotes;  they  change  silver  nitrate  into  an  insoluble 
silver  chlorid.  For  internal  treatment,  lavage  of  the  stomach  with 
salt  water  and  large  draughts  of  milk  or  white  of  egg  solutions 
are  recommended.  As  sodium  chlorid  is  irritating  to  the  stom- 
ach, it  should  not  be  given  in  too  concentrated  solutions.  In  typi- 
cal chronic  poisoning  (argyria)  potassium  iodid  may  be  beneficial 
in  aiding  the  elimination  of  the  silver  salts.  Local  argyria  is 
sometimes  met  as  a  result  of  prolonged  application  of  silver  nitrate 


228  PHARMACO-THERAPEUTICS 

in  the  mouth,  the  eyelids,  etc.  Seheff  describes  a  case  of  dental 
argyria  in  which  the  persistent  application  of  the  silver  salt  pro- 
duced permanent  stains  on  a  number  of  teeth. 

Within  recent  years  a  number  of  compounds  of  silver  with  or- 
ganic acids  have  appeared  on  the  market,  which  for  a  short  time 
were  inclined  to  be  considered  equal  in  their  action  to  silver  ni- 
trate. Prominently  among  these  salts  are  silver  citrate,  known 
as  itrol,  and  silver  lactate,  known  as  actol.  Both  salts  were  intro- 
duced by  Crede.  Silver  citrate  is  a  white  powder,  soluble  in 
3,000  parts  of  water;  it  is  nonirritating,  and  has  been  employed 
as  a  dusting  powder  on  wound  surfaces.  Silver  lactate,  a  white 
powder,  is  soluble  in  15  parts  of  water ;  it  is  caustic  even  in  diluted 
solutions.  Both  silver  salts  and  their  solutions  must  be  protected 
from  light;  they  stain  the  tissues  black.  Silver  acetate,  another 
compound  of  this  group,  has  never  been  employed  therapeutically 
to  any  extent.  Crede  further  recommended  a  form  of  colloidal 
silver  known  as  collargol — metallic  silver  in  an  extremely  fine 
state  of  division,  which  is  soluble  in  water  and  albuminoid  fluids. 
It  was  claimed  that  when  collargol  was  introduced  into  the  body 
by  inunction  or  by  intravenous  injection,  it  would  exercise  a 
powerful  germicidal  influence.  As  collargol  possesses  no  bacterial 
action,  these  claims  have  not  been  substantiated.  Actol  and  itrol 
possess  only  historical  interest  at  present  while  collargol  is  still 
used  and  much  lauded  as  a  serviceable  antiseptic  in  oral  surgery. 

Argentamin  is  a  protein  silver  compound,  representing  a  solu- 
tion of  silver  phosphate  in  ethylendiamin.  In  preparing  this 
compound  it  was  hoped  to  increase  the  action  of  silver  by  adding 
an  alkali,  which  exercises  a  high  solvent  power  on  the  cell  wall 
of  the  micro-organisms.  Theoretically  this  is  correct,  but  it  was 
found  that  the  alkaline  diamin  proved  to  be  too  irritating  to  the 
tissues.  Largin,  an  albuminate  of  silver,  and  protargol,  a  protein 
silver  compound,  are  among  the  more  recent  prominent  silver 
preparations.  Argonin,  a  casein-silver  compound,  appears  as  a 
white  neutral  powder,  insoluble  in  cold,  but  freely  soluble  in  hot 
water.  It  is  not  precipitated  by  the  tissue  fluids,  but  cocain, 
eucain,  and  the  heavy  metals  quickly  reduce  its  solution.  It  is 
claimed  that  15  grains  of  argonin  contain  as  much  silver  as  one 
grain  of  silver  nitrate.  It  is  used  in  2  to  10  per  cent  solutions. 
Alhargol  or  alhargin  is  a  w^hite,  readily  soluble  powder,  represent- 
ing a  gelatin-silver  compound.     It  is  employed  in  0.1  to  1  per 


CAUSTICS  229 

cent  solutions.  Still  more  recently  a  protein  silver  compound, 
which  is  stated  to  be  silver  vitellin,  is  known  as  argyrol.  It  ap- 
pears in  dark-brown  scales,  tasteless  and  odorless,  very  hygro- 
scopic, and  very  readily  soluble  in  water.  It  produces  a  super- 
ficial dark-brown  stain,  which  is  readily  washed  away;  it  has  no 
cauterant  effects  on  the  tissues.  It  may  be  applied  in  substance 
or  in  aqueous  solutions.  Nargol,  an  organic  compound  of  silver 
and  nucleinic  acid  (yeast-nuclein)  is  a  brownish  powder,  and 
readily  soluble  in  water.  It  is  employed  much  in  the  same  man- 
ner as  protargol.  Silverol,  a  phenolsulphate  of  silver,  and  ar- 
gentol,  a  combination  of  silver  with  chinosol,  are  merely  men- 
tioned to  complete  the  list. 

According  to  a  recent  examination  by  Marshall  and  Neane,  the 
percentage  of  silver  present  in  the  more  important  silver  com- 
pounds was  determined  with  the  following  results : 

Percentage  of  Silver. 

Collargol 86.6 

Silver    Nitrate    63.6 

Silver  Citrate   60.8 

Silver  Lactate    51.5 

Argentol 31.2 

Argyrol 20.0 

Albargin 13.4 

Nargol    9.6 

Protargol    7.4 

Argeutamin    6.4 

The  experiments  showed  that  as  regards  bactericidal  action  the 
various  silver  compounds  investigated  fall  into  three  groups: 
First,  those  which  are  powerfully  bactericidal,  i.  e.,  silver  nitrate, 
silver  lactate,  silver  citrate,  argentamin,  argentol,  albargin,  and 
protargol;  Second,  one  silver  compound — nargol — much  less 
powerful  bactericidal;  and  third,  two  silver  compounds — argyrol 
and  collargol — which  possess  practically  no  bactericidal  action 
whatever.  The  bactericidal  action  of  these  compounds  in  solu- 
tion containing  the  same  percentage  of  combined  silver  is  closely 
similar  and  it  is  practically  impossible  to  place  them  in  any  order 
of  activity  which  would  be  true  under  all  circumstances.  As 
argyrol  and  collargol  are  not  bactericidal,  it  is  evident  that  the 
amount  of  silver  which  a  compound  may  contain  is  no  criterion  of 
its  bactericidal  pov^^er.     Clark    and    Wylie    have    made    similar 


230 


PHARMACO-THERAPEUTICS 


bactericidal  studies;  the  following  table  is  an  example  taken  from 
their  publication: 


Organism 

Solution 

Number  of  colonies  from  one  loopful 
taken  after 

5  minutes 

10  minutes 

30  minutes 

Streptococcus. . . . 

2.   percent 

silver  nitrate 
1 .   percent 

silver  nitrate 
10.   percent 

protargol 
30.   percent 
argyrol 
10.  percent 
argyrol 
2.5  percent 
collargol 

0 
6 

25 
0 
4 

15 

0 
5 
20 
0 
0 
8 

0 
0 

20 
0 
0 
0 

Of  all  the  above  named  organic  silver  compounds,  albargin  and 
protargol  are  by  far  the  most  favored  ones.  They  deserve  to  be 
recommended  as  general  antiseptics.  For  irrigation  of  the 
maxillary  sinus,  weak  solutions  of  from  i/o  to  1  per  cent  are  em- 
ployed, while  for  alveolar  abscesses  from  10  to  20  per  cent  solu- 
tions should  be  used.  The  solutions  should  always  be  freshly  pre- 
pared with  cold  water  and  kept  in  a  colored  bottle ;  heat  and  light 
cause  rapid  oxidation  of  the  solutions,  which  are  then  strongly  ir- 
ritating to  the  tissues.  The  following  working  formula  is  recom- 
mended for  the  preparation  of  a  suitable  solution: 


gr.  v-xxx   (0.32-2.0  Gm.) 
gtt.  XV   (1  Co.) 


IJ     Protargol  vel  albargin. 
Glycerin. 
Sol.  sod.  chlorid.  (0.9  per 

cent)  flS  iv  (120  C.c.) 

M. 

Sig. :  Place  the  glycerin  in  a  dry  mortar,  add  the  silver 
compound  and  mix  to  a  paste;  then  add  the  water  in  a  slow 
stream  with  constant  stirring. 


Arsenic  Trioxid;  Abseni  Trioxidum,  U.   S.  P. 
Arseniosum,  B.  p.;  AS2O3. 


ACIDUM 


Etymology. — From  the  Greek  arsenikon,  which,  however,  des- 
ignates what  is  known  at  present  as  orpiment  or  auripigment, 
or  king's  yellow,  the  native  arsenic  trisulphid. 


CAUSTICS  231 

Synonyms. — Arsenous  acid,  arsenous  anhydrid,  arsenicum  al- 
bum ;  acide  arsenieux,  F. ;  Arsenige  Saure,  G. ;  arsenico  bianco, 
Sp. 

Source  and  Character. — Arsenous  trioxid  is  not  a  true  acid 
(absence  of  hydrogen)  ;  it  is  obtained  by  roasting  arsenical  ores. 
In  Bohemia  and  Saxony  it  is  largely  produced  from  smelting 
crude  cobalt  ores,  and  in  England  from  arsenopyrite,  known  as 
mispickel,  or  arsenical  iron.  It  appears  in  transparent,  porce- 
lain-like masses;  they  change  slowly  to  an  opaque  milk-white  color 
or  to  a  fine  white  powder.  It  has  no  taste  or  odor,  and  at  356°  F. 
(180°  C.)  it  is  entirely  volatilized  by  heat.  When  thrown  on  ignited 
charcoal  it  emits  a  garlic-like  (alliaceous)  odor.  It  is  slowly 
soluble  in  from  30  to  100  parts  of  water  at  ordinary  temperature, 
depending  on  the  variety  employed.  It  is  completely  soluble  in 
15  parts  of  boiling  water  and  in  about  5  parts  of  glycerin,  and 
sparingly  soluble  in  alcohol.  It  is  incompatible  with  the  salts  of 
iron  and  magnesium,  with  lime  water,  and  astringent  vegetable 
drugs. 

Average  Dose.— ^^q  gi'ain   (0.002  Gm.). 

Preparations. — 

Liquor  Acidi  Arsenosi,  U.  S.  P. ;  Liquor  Arsenici  Hydrochlor- 
icus,  B.  P.  A  1  per  cent  solution  of  arsenic  trioxid  acidulated 
with  hydrochloric  acid. 

Liquor  Potasii  Arsenitis,  U.  S.  P. ;  Liquor  Arsenicalis,  B.  P. 
Fowler's  solution,  a  1  per  cent  solution  of  arsenic  trioxid  neutral- 
ized with  potassium  bicarbonate,  and  colored  and  flavored  with 
compound  tincture  of  lavender.  Average  dose,  3  minims  (0.2 
C.c). 

Liquor  Arseni  et  Hydrargyri  lodidi,  U.  S.  P.,  B.  P.  Donovan's 
solution,  containing  1  per  cent  each  of  arsenous  iodid  and  red 
mercuric  iodid.     Average  dose,  l^/o  minims  (0.1  C.c). 

Medical  Properties. — Antipyretic,  antiseptic,  alterative,  and 
tonic. 

Local  and  General  Action. — If  arsenic  is  applied  to  the  un- 
broken skin,  no  change  is  produced,  unless  allowed  to  remain  in 
close  contact  for  some  time.  On  denuded  surfaces  and  mucous 
membranes  it  acts  as  a  slow,  but  very  persistent,  protoplasm 
poison  by  powerful  oxidation ;  it  does  not  form  new  compounds 
with  the  albuminous  or  protein  materials  of  the  cells.  Arsenic 
trioxid  does  not,  therefore,  act  as  a  caustic,  nor  is  it  self-limiting 


232  PHARMACO-THERAPEUTICS 

in  its  action.  It  has  a  predilection  for  necrobiotic  tissue,  produc- 
ing true  necrosis  in  due  time.  Taken  internally,  arsenic  acts  as 
a  powerful  irritant,  resulting  in  vomiting,  pain,  and  inflammation. 
It  does  not  combine  with  the  albuminous  contents  of  the  stomach 
or  intestines,  but  remains  unchanged.  Thus  it  stimulates  the 
nerves  and  vessels,  and  causes  a  sense  of  hunger  by  increasing 
the  gastric  functions.  It  is  readily  absorbed  and  quickly  enters 
the  blood.  In  overdoses,  arsenic  is  extremely  poisonous.  It 
manifests  itself  in  a  feeling  of  constriction  in  the  throat,  in  diffi- 
culty of  swallowing,  and  violent  pain;  "rice  water"  stools  or 
bloody  diarrhea,  accompanied  by  diminished  urine;  cold,  damp 
skin,  together  with  giddiness,  feeble  pulse  and  respiration  follow, 
soon  ending  in  collapse.  Chronic  poisoning  usually  follows  the 
prolonged  absorption  of  small  quantities,  either  from  its  thera- 
peutic use  or  from  the  presence  of  arsenic  in  the  rooms  in  the 
form  of  dyes  on  Avail  paper,  clothes,  or  in  mines  and  factories.  If 
arsenic  is  taken  habitually  in  small  quantities,  a  tolerance  to  the 
drug  may  be  established,  as  with  the  arsenic  eaters  of  Styria  and 
the  Tyrol.  As  much  as  seven  grains  have  been  taken  without  ill 
effects  at  a  single  dose  by  a  person  accustomed  to  its  use.  It 
is  claimed  that  it  will  improve  the  complexion  and  general  ap- 
pearance. 

Specific  Action  of  Arsenic  Trioxid  on  the  Tooth  Pulp.  In  1833 
Wood  advocated  the  use  of  crude  arsenic  (flystone,  ratsbane,  or 
native  cobalt  bloom)  for  the  destruction  of  the  dental  pulp. 
Three  years  later,  in  1836,  Dr.  Shearjashub  Spooner,^  of  New 
York,  published  an  excellent  little  book  entitled  "Guide  to  Sound 
Teeth,  or  a  Popular  Treatise  on  the  Teeth,"  in  which  he  recom- 
mended to  the  dental  profession  for  the  first  time  the  use  of 
arsenic  trioxid  for  the  above  purpose.  "The  nerves  of  the  teeth 
may  be  certainly  and  effectually  destroyed,  with  little  or  no  pain 
to  the  patient  and  without  the  least  danger,  by  means  of  a  little 
arsenous  acid  applied  to  the  nerve."  Spooner  claims  to  have 
learned  this  invaluable  discovery  from  his  brother.  Dr.  John  K. 
Spooner,  of  Montreal,  Canada.  It  is  stated  that  Dr.  Chaplin  Har- 
ris, of  Baltimore,  used  arsenic  in  1835  wdthout  having  knowledge 
of  Spooner 's  discovery.  Arsenic  Avas,  however,  utilized  by  den- 
tists for  other  purposes  as  early  as  the  beginning  of  the  Christian 

^  Spooner:  Guide  to  Sound  Teeth,  or  a  Popular  Treatise  on  the  Teeth,  1836. 


CAUSTICS  233 

era,  as  recorded  by  Celsus  in  his  work,  ''De  Re  Medica."  The 
Persian  and  Arabian  physicians  (Rhazes,  Ebn  Sina,  Abulcasis, 
and  others)  frequently  refer  to  the  use  of  sandarach,  the  Arabian 
term  for  red  sulphid  of  arsenic;  in  the  form  of  a  paste  it  was  ap- 
plied about  the  roots  of  teeth  to  facilitate  their  ready  removal. 

Spooner's  announcement  of  the  reliability  of  arsenic  as  a  means 
of  destroying  the  dental  pulp  met  with  violent  opposition,  and 
even  as  late  as  1847  we  read  in  Burdell:^  "Suppose  you  have 
arsenic  applied  to  the  nerve  of  a  tooth — it  will  act  until  its 
strength  is  wasted ;  the  action  is  toward  the  brain  and  spinal  mar- 
row. It  may  destroy  the  nerve  in  the  tooth  and  go  on  half  way 
to  the  brain,  or  wholly  to  it,  carrying  death  to  the  parts,  which 
can  never  recover."  More  broadminded  men,  however,  like  Dun- 
ning, Foster,  Maynard,  Westcott,^  and  others,  strongly  urged  the 
advantages  of  arsenic  over  the  old  method  of  knocking  out  the 
pulp,  or  the  slow-acting  caustics — as  silver  nitrate,  nitric  acid, 
etc. — which  were  in  vogue  at  that  time. 

In  1885  Adolph  WitzeP  published  his  memorable  work,  "A 
Compendium  of  the  Pathology  and  Therapeutics  of  the  Diseases 
of  the  Pulps  of  the  Teeth,"  in  which  he  tried  to  explain  the  ac- 
tion of  arsenic  as  follows:  Arsenic  acts  on  diseased  parts  of  the 
pulp  only,  causing  an  increased  influx  of  blood  into  the  healthy 
parts.  A  deeper  penetration  of  the  drug  through  the  entire  pulp 
and  through  the  foramen  is  excluded ;  no  chemic  disintegration 
of  the  dentin  takes  place.  Miller*  studied  the  action  of  arsenic 
on  the  pulps  of  teeth  of  dogs  and  rabbits,  and  on  the  tails  of  white 
mice.  In  some  cases  he  placed  a  small  glass  ring  over  the  tail, 
fastening  it  securely  over  its  root,  thus  resembling  somewhat  the 
constricted  apical  foramen  of  the  tooth.  In  other  cases  he  encased 
the  entire  tail  in  a  batter  of  plaster  of  Paris  after  previously  ap- 
plying a  small  amount  of  arsenic  into  a  pouch  under  the  skin. 
The  most  pronounced  symptoms  in  the  latter  cases  manifested 
themselves  in  an  intense  edematous  swelling.  The  entire  back 
and  the  hind  limbs  were  involved,  accompanied  by  pronounced 
anesthesia  of  these  parts  and  paralysis  of  the  legs,  which  results 
usually  in  twenty-four  to  thirty-six  hours^  depending  on  the  quan- 

iBurdell:  Teeth,  Their  Structure  and  Diseases,  1847. 
'History  of  Dental  and  Oral  Science  in  America,  1876. 

*  A.  Witzel:  Compendium  der  Pathologie  und  Therapie  der  Pulpakrankheiten,  1883. 

*  Miller:  Lehrbuch  der  Konservativen  Zahnheilkunde,   1906. 


234 


PHARMACO-THERAPEUTICS 


tity  of  arsenic  used.  In  those  cases  in  which  the  glass  ring  has 
been  placed  over  the  roots  of  the  tail  and  the  part  distally  of  the 
ring  receives  a  small  quantity  of  arsenic,  this  latter  part  alone 
will  be  affected.  Hyperemia,  followed  by  inflammation  and 
necrosis  with  complete  separation  of  the  tail  usually  occurs  with- 
in a  week.  Arkovy^  presented  a  thorough  investigation  of  the 
arsenic  before  the  International  Medical  Congress  in  London,  in 
1801.     A  short  resume  of  his  work  will  be  of  greatest  interest: 


Fig.  39. 

Action  of  arsenic  (24  hours'  application)  on  the  human  tooth  pulp  (upper  canine).    A  and  B, 
Total  destruction,  followed  below  by  beginning  of  necrosis.     (Schroder.) 


According  to  the  amount  of  arsenic  used,  a  partial  or  total 
hyperemia  of  the  pulp  will  be  the  result.  The  blood  vessels  en- 
large and  show  signs  of  thrombosis,  and  embolism  of  the  capil- 
laries results.  The  red  blood  corpuscles  lose  their  color  most 
likely  as  a  result  of  the  chemic  combination  of  the  arsenic  with 


^Arkovy:  Transactions  International  Medical  Congress,   1881. 


CAUSTICS  235 

the  hemoglobin,  causing  anemic  collapse  and  shrinkage.  The 
connective  tissue  fibers  and  the  odontoblasts  are  not  changed, 
while  the  connective  tissue  cells  are  greatly  enlarged.  The  axis- 
cylinders  of  the  nerve  cells  usually  disappear;  the  nerve  cells 
themselves  show  a  granular  debris  within  the  myelin. 

Other  investigators  followed.  The  writings  of  Herz-Frankl  and 
Schenk,^  Julius  Witzel,^  Morgenstern,^  and  Greve,*  and  the  classic 
researches  of  Gubler,^  on  the  therapeutic  action  of  this  important 
drug  are  highly  interesting.  Binz  and  Schulz  explain  the  phar- 
macologic action  of  arsenic  trioxid  as  follows:  When  arsenic 
trioxid  is  absorbed  by  the  living  tissue,  it  is  changed  by  the 
sodium  present  in  the  body  fluids  into  sodium  arsenite,  and  its 
solution  becomes  ionized.  The  arsenic  oxid  ion,  ASO2,  possesses  a 
powerful  reducing  action  on  the  tissues,  changing  it  to  an  arsen- 
ate. The  latter,  in  turn,  is  again  reduced  to  an  arsenite  by  the 
reducing  action  of  the  tissues.  The  perpetual  oxidation  and  re- 
duction within  the  cell  causes  a  violent  oscillation  of  the  atoms 
of  active  oxygen,  and  this  is  the  cause  of  its  therapeutic  and  toxic 
effect.  Within  the  cell  proper,  irritation  is  the  immediate  result, 
followed  by  cloudy  swelling,  fatty  degeneration,  and  finally  by 
necrosis.  The  metalloid  arsenic  merely  plays  the  role  of  an  au- 
toxidizer.  According  to  Filehne,  all  members  of  the  arsenic- 
phosphorus-antimony  group  act  very  much  in  the  same  manner 
as  arsenic  trioxid.  Arsenic  trioxid  is  not  a  coagulant  of  albumin, 
or  only  very  slightly  so,  and  its  action  is  practically  unlimited; 
besides,  the  chemical  is  readily  absorbed  and  very  diffusible. 
These  factors  are  responsible  for  its  deep  action. 

The  specific  action  of  arsenic  on  the  tooth  pulp  may  be  epit- 
omized as  follows :  If  applied  to  an  exposed  normal  pulp,  it  is 
readily  absorbed.  Pronounced  hyperemia  and,  consequently,  in- 
creased pain  are  the  early  manifestations  of  the  arsenic  action. 
"The  walls  of  the  capillaries  are  exceedingly  delicate,  being 
formed  by  a  single  layer  of  endothelium,  which  is  a  continuation 
of  the  endothelial  lining  of  the  arteries  on  the  one  side  and  the 


1  Herz-Frankl  und  Schenk:  Osterreichisch-Ungarische  Vierteljahrsschrift  fur  Zahnheil- 
kunde,  1895,  No.  2. 

2  J.  Witzel:  Correspondenzblatt  fur  Zahnheilkunde,   1898,  No.  2. 

*  Morgenstern:  Correspondenzblatt  fiir  Zahnheilkunde,   1903,  No.   1. 

*  Greve:   Correspondenzblatt  fiir  Zahnheilkunde,    1903,   No.   4. 

*  Gubler:  Commentaires  Therapeutiques  du  Cotex,  1891. 


236 


PHARMACO-THERAPEUTICS 


veins  on  the  other."  (A.  Hopewell-Smith.)  The  endothelial  coat 
of  the  capillaries  is  quickly  corroded,  causing  multiple  hemor- 
rhage. Destruction  of  the  blood  plates — plasmolysis  and  plasmor- 
hexis — immediately  follows,  resulting  in  granular  detritus.  Throm- 
bosis and  stasis  are  the  direct  sequences.  The  connective  tissue 
fibers  and  the  odontoblasts  are  but  little  altered.  The  primary 
point  of  attack  on  the  nerve  centers  is  located  in  their  endings, 
causing  a  destruction  of  the  myelin  and  a  more  or  less  pronounced 


Fig.  40. 

Section  of  o  and  b  of  Fig.  39  under  higher  magnification,  a,  Complete  necrosis  with 
total  loss  of  structure;  b.  Fixed  zone  of  cells  with  stained  nuclei;  c.  Beginning  of  necrosis. 
(Schroder.) 


neuritis;  the  latter  is  usually  followed  by  complete  cessation  of 
all  pain.  The  pronounced  disturbances  of  nutrition  finally  re- 
sult in  anemic  collapse  and  shrinkage  of  the  entire  pulp  mass. 
On  pathologically  altered  pulps  arsenic  acts  very  much  in  the 
same  manner,  but  decidedly  slower,  depending  largely  on  the 
stage  of  inflammation  and  the  character  of  the  exudates.  An  ex- 
isting neuritis  is  always  markedly  increased.     Depending  on  the 


CAUSTICS  237 

vascularity  and  the  size  of  the  pulp,  and  the  quantity  used,  from 
a  few  hours  to  two  to  five  days  are  usually  required  for  its  pro- 
gressive destruction.  Strangulation  of  the  pulp  about  its  apical 
end,  resulting  from  the  intense  hyperemia  brought  about  by  the 
action  of  arsenic,  is  not  the  direct  cause  of  its  death;  in  teeth 
with  undeveloped  roots  or  in  those  with  partially  absorbed  roots, 
strangulation  is  very  doubtful. 

Arsenic  is  not  a  caustic — that  is,  it  does  not  cause  a  coarse 
chemic  or  physical  alteration  of  the  cell  body;  it  is  a  true  proto- 
plasm poison,  its  toxic  action  being  based  on  a  chemic  reaction 
within  the  cell  body  proper. 

Therapeutics. — Since  the  introduction  of  arsenic  trioxid  for 
the  purpose  of  destroying  the  dental  pulp  many  substitutes  have 
been  advocated,  but  none  have  so  far  superseded  it  or  taken  its 
place.  Crude  arsenic,  known  as  cobalt,^  flystone,  ratsbane,  or  by 
other  synonyms,  has  been  much  lauded  by  such  practitioners  as 
Arthur,  Allport,  Taft,  Herbst,  Dorn  and  others.  It  contains  a 
very  uncertain  amount  of  arsenic,  and  possesses  no  advantage 
over  the  pure  chemical.  Aside  from  the  use  of  local  anesthetics  by 
special  methods,  arsenic  trioxid  is  still  the  most  universal  agent 
employed  for  the  above  purpose.  Usually  it  is  applied  in  the 
form  of  a  paste,  sometimes  as  arsenical  fiber  or  discs,  and  as  a 
dry  powder. 

Innumerable  formulas  for  compounds  of  arsenic  with  other 
drugs  are  suggested  for  dental  purposes.  The  principal  object 
has  always  been  to  combine  the  arsenic  with  an  anesthetic.  Many 
of  the  published  formulas  represent  empirical  compounds,  which 
are  put  together  in  utter  disregard  of  the  pharmacologic  action 
of  the  individual  drugs.  If  the  pulp  is  in  a  normal  condition, 
very  little  or  no  pain  is  manifested  by  the  arsenical  application; 
if  the  nerve  cells  are  inflamed    or    are    undergoing    necrobiotic 


*  Cobalt,  chemically,  is  a  metal  of  steel-gray  color,  hard,  ductile,  and  of  a  high  melting 
point,  resembling  iron  in  its  general  characteristics.  It  is  rarely  used  in  medicine.  Unless 
specified,  this  metal  cobalt  is  not  sold  in  drug  stores.  A  number  of  its  compounds,  consist- 
ing largely  of  cobalt  in  conjunction  with  arsenic,  nickel,  iron,  manganese,  etc.,  are  found 
in  nature,  and  are  commonly  called  crude  cobalt,  cobalt  ore,  native  cobalt-bloom,  or  simply 
cobalt.  Metallurgists  distinguish  quite  a  number  of  cobalt  varieties,  according  to  their  com- 
position— as  smaltine,  tin-white  or  speiss  cobalt,  crude  metallic  arsenic,  flystone  or  "Scher- 
ben  cobalt,"  etc.  (composed  of  about  70  per  cent  of  arsenic  with  cobalt,  nickel,  sulphur, 
etc. — a  heavy,  black  powder,  and  usually  sold  by  the  name  of  "cobalt"),  cobalt-bloom, 
erythrine  or  native  cobaltic  arsenate  (with  about  38  per  cent  arsenic — a  deep-blue  powder), 
cobalt-glance  (with  about  45  per  cent  arsenic),  earthy  cobalt  or  wad  (with  no  arsenic),  etc 


238 


PHARMACO-THERAPEUTICS 


changes,  the  increased  irritation  brought  about  by  the  powerful 
oxidation  and  reduction  as  a  result  of  the  pharmacologic  action 
of  arsenic  increases  the  already  existing  neuritis,  and  more  or  less 
severe  pain  results.  Arsenic  is  very  diffusible;  it  quickly  de- 
stroys the  nerve  endings,  and  consequently  there  is  little  chance 
for  the  anesthetic  which  may  be  added  to  it  to  exercise  its  specific 
function.  For  this  very  reason  the  addition  of  a  local  anesthetic 
is   of  no  benefit.     For  many    years    the    original    formula    of 


Fig.  41. 

Necrosis   of  pulp   after   application  of  arsenic    (24   hours'   duration).      A,    Total    necrosis; 
B,    Beginning   of  necrosis;    E,    Ecchyniosis.      (Romer.) 

Spooner,  consisting  of  arsenic  trioxid,  morphin  acetate,  and 
creosote,  has  been  and  is  still  used  with  apparent  good  success. 
Morphin  applied  locally  has  no  anesthetic  or  narcotic  effect  on 
sensory  nerve  endings,  and  consequently  it  acts  merely  as  a  dilu- 
ent of  the  arsenic.  Cocain  or  its  substitutes,  added  to  arsenic  with 
the  expectation  of  mitigating  the  pain  or  the  irritating  effect  of 
the  latter,  is,  to  say  the  least,  questionable.      Scientific    proof    of 


CAUSTICS 


239 


this  supposition  has  certainly  never  been  brought  forward.  Never- 
theless there  is  less  objection  to  their  use  than  to  most  of  the 
other  narcotics.  Additions  of  aconite,  eserin,  opium  or  its  salts, 
iodoform,  etc.,  are  useless,  as  they  simply  interfere  with  the  ready 
absorption  of  arsenic.  Thymol,  menthol,  the  essential  oils,  etc., 
are  painful  anesthetics;  their  action  is  too  slow  to  be  of  value  in 
this  connection.  A  more  rational  procedure  consists  in  applying 
to  an  aching  pulp  a  concentrated  solution  of  a  local  anesthetic — 
cocain,  novocain,  etc. — prior  to  the  introduction  of  the  arsenical 
paste.  The  addition  of  an  antiseptic  to  the  arsenical  paste  is  il- 
logical.    Arsenic  is  a  powerful  antiseptic  in  itself,  although  it  is 


Fig.  42. 

Enlarged  section  of  Fig.   41.     t,ine  of  demarcation  between  total  and  partial 
necrosis.      (Romer.) 


a  well-known  fact  that  the  cell  walls  of  the  lower  organisms  (bac- 
teria) possess  a  greater  resistance  to  its  action  than  those  of  the 
higher  organized  cells.  Tanning  agents  are  frequently  added  to 
the  paste  for  the  purpose  of  changing  the  pulp  tissue  to  a  leathery 
material,  so  as  to  facilitate  its  ready  removal.  Tannic  acid  or  the 
various  forms  of  formaldehyd  are  used  for  this  purpose.  It  is 
better  practice  to  apply  such  agents  after  the  arsenic  dressing  has 
been  removed ;  the  less  we  interfere  with  the  absorption  of  the  ar- 
senic, the  better  and  quicker  will  be  the  results.  Incidentally, 
some  of  these  agents,  like  tannic  acid,  may  cause  discoloration  of 


240  PHARMACO-THERAPEUTICS 

the  tooth's  structure.  As  a  vehicle  for  the  paste,  only  such  media 
as  are  more  or  less  solvents  of  arsenic,  or  which  allow  its  ready 
absorption  by  the  pulp,  are  justified.  Glycerin,  lanolin,  vaselin, 
phenol,  cresote,.or  the  essential  oils,  and  similar  liquids,  have  been 
used  for  many  years  as  vehicles  for  the  paste;  their  influence  on 
the  action  of  arsenic  is  apparently  of  very  little  consequence ; 
they  certainly  do  not  exercise  their  typical  pharmacologic  action 
in  this  connection.  Strong  coagulants  should  not  be  used,  as 
they  hinder  the  ready  absorption  of  the  poison  by  forming  a 
scab. 

To  give  a  distinct  color  to  the  paste,  very  small  quantities  of 
lamp  black  or  carmin  may  be  added.  Some  practitioners  prefer 
to  apply  arsenic  in  the  form  of  a  paste  mixed  with  cotton  fibers, 
or  in  the  form  of  paper  discs  saturated  with  a  soft  paste.  Arseni- 
cal fiber  is  prepared  by  mixing  cross-cut  cotton  with  the  paste, 
and  the  discs  are  made  by  saturating  very  small  squares  of  hard 
white  blotting  paper  with  the  thin  paste,  which  are  then  dried 
and  preserved. 

Prior  to  the  application  of  arsenic,  the  cavity  must  be  ex- 
cavated, as  arsenic  will  not  act  through  carious  dentin,  and,  if  pos- 
sible, the  pulp  should  be  exposed  and  thoroughly  depleted,  either 
by  puncturing  the  organ  or  by  applying  vaso-constrictor  drugs. 
Szabo^  recommends  lavage  for  this  purpose — washing  the  pulp 
with  lukewarm  water,  changed  slowly  to  cold  water.  Quicker  re- 
sults are,  however,  obtained  by  applying  epinephrin  chlorid  solu- 
tion under  pressure.  The  cavity  must  be  free  from  blood,  to  pre- 
vent the  formation  of  inactive  arsenic  hemoglobin.  If  the  pulp 
is  inflamed  and  painful,  it  is  absolutely  necessary  to  apply  suit- 
able remedies  to  relieve  the  conditions  before  the  paste  is  applied ; 
an  inflamed  pulp  materially  hinders  the  ready  absorption  of  ar- 
senic, and  continuous  severe  pain  is  certain  to  follow.  A  mix- 
ture of  cocain  or  novocain  hydrochlorid,  and  liquid  phenol  is 
serviceable  for  this  purpose.  These  remedies,  if  sealed  into  the 
cavity,  usually  alleviate  the  condition  in  from  twenty-four  to 
forty-eight  hours.  If  pus  is  present,  it  must  be  drained  off.  Pulp 
nodules  occasionally  obstruct  the  ready  diffusibility  of  the  chemi- 
cal. Removal  of  these  calcareous  deposits  by  means  of  sulphuric 
acid  or  by  a  drill,  after  cocain  pressure  anesthesia  has  been  ap- 


'  Szabo:   Osterreichisch-Ungarische  Vierteljalirsschrift   fiir  Zahnheilkunde,   1903,   No.  2. 


CAUSTICS 


241 


plied,  is  indicated.  Cocaiii  should  never  be  applied  cataphorical- 
ly  under  these  conditions,  as  the  electric  current  may  drive  the 
previously  applied  arsenic  through  the  apical  foramen  into  the 
soft  tissues.  Fletcher^  reports  a  case  of  this  nature,  resulting  in 
severe  inflammation  of  the  pericementum.  Hitter-  warns  against 
the  application  of  arsenic  during  pregnancy,  claiming  that  the 
teeth  are  less  resistant  and  softer.     Occasionally  one  meets  a  pa- 


Z,^:^     ^^y\ 

-^'It  -^ 


.^'  A    :\^ .  fit 


7^ 


Fig.  43. 

Total  necrosis  of  pulp  after  six  days'  arsenic  application.     Cells,  vessels  and  nerves  have 
disappeared,  only  unstained  strands  of  connective  tissue  are  remaining.     (Romer.) 


tient  who  presents  an  unexplained  idiosyncrasy  to  the  action  of 
this  chemical. 

The  cavity  for  the  reception  of  the  arsenical  application  should 
be  of  ready  access,  and  so  prepared  as  to  easily  retain  the  tem- 
porary filling.     The  arsenical  compound  is  preferably  placed  in 


1  Fletcher:  Ohio  Dental  Journal,  1891. 
»Ritter:  Zahn  und  Mundleiden,  1899. 


242  PHARMACO-THERAPEUTICS 

direct  contact  with  the  freely  exposed  pulp  by  means  of  a  blunt 
instrument,  or  on  a  depressed  metallic  disc  or  a  piece  of  cardboard, 
or  on  cotton  or  spunk.  Close  contact  insures  quick  action.  Ar- 
senic will  act  by  osmosis,  although  slower,  through  any  thickness 
of  dentin.  This  very  fact  is  the  reason  its  use  as  a  remedy  for 
hypersensitive  dentin  has  been  abandoned;  death  of  the  pulp  was 
invariably  the  sequence  of  such  a  procedure.  Some  operators  pre- 
fer to  cover  the  arsenical  dressing  with  an  intermediate  film  of 
plain  or  oiled  paper,  or  a  pledget  of  cotton.  The  final  sealing  of 
the  cavity  consists  of  a  temporary  filling  of  cement  or  of  a  gutta- 
percha preparation.  Extreme  care  should  be  exercised  in  this 
simple,  yet  most  important,  operation.  Cotton  fibers  mixed  with 
sandarac  or  mastic  varnish,  to  be  used  as  a  retaining  medium, 
should  be  avoided;  they  readily  become  foul  in  the  fluids  of  the 
mouth,  or  they  may  leak,  and,  besides,  they  swell,  causing  pain 
from  pressure  on  the  pulp.  Kirk  has  advocated  the  use  of  sur- 
geon's rubber  plaster  where  but  a  portion  of  the  tooth  is  left, 
carrying  it  around  the  tooth;  it  will  adhere  satisfactorily  for 
several  days,  or  long  enough  to  accomplish  the  object.  The  gutta- 
percha preparations  are  the  best  media  for  a  temporary  dressing 
seal;  most  experienced  operators  agree  that  a  cavity  correctly 
sealed  with  this  material  offers  less  possibilities  for  the  seeping 
through  than  the  various  cements  or  other  materials.  In  Europe 
Fletcher's  artificial  dentin  is  used  universally  for  such  work.  In 
applying  the  temporarj^  stopping,  it  is  very  essential  to  avoid 
pressure  on  the  dressing.  In  approximal  cavities,  where  over- 
hanging tooth  substance  prevents  ready  access,  and  therefore  pre- 
sents danger  of  misplacing  the  arsenical  dressing,  gutta-percha 
packed  between  the  two  teeth,  and  thus  acting  as  a  splint,  is  of 
service. 

The  quantity  of  arsenic  necessary  for  the  destruction  of  a  pulp 
is  very  small.  A  careful  estimation  based  on  diverse  weighings 
of  quantities  of  arsenical  paste  as  employed  by  several  practi- 
tioners in  their  routine  work  has  shown  that  the  average  applica- 
tion weighs  about  Ysq  grain  (0.002  Gm.).  It  is  not  only  useless, 
but  decidedly  dangerous,  to  employ  more.  Other  writers,  i.  e., 
Arkovy,  Gorgas,  Clifford,  Lipschitz,  Bannag,  etc.,  have  estimated 
the  amount  as  varying  from  one-hundredth  to  a  twentj'-fifth  of  a 


CAUSTICS  243 

grain.  According  to  Von  Metnitz^  the  same  little  pellet,  charged 
with  an  arsenical  paste,  which  had  killed  successively  sixteen 
pulps,  still  retained  enough  arsenic  to  cause  necrosis,  in  the  leg  of 
a  frog. 

In  deciduous  teeth,  and  in  those  of  young  persons  where  the 
roots  have  not  fully  formed,  the  arsenical  paste  should  be  left 
in  the  cavity  only  a  very  short  time.  To  illustrate  the  danger  of 
arsenic  used  on  such  teeth,  Martin^  reports  the  following  case  in 
which  he  applied  the  paste  on  the  pulp  of  a  lateral  incisor:  "The 
devitalization  agent  passed  out  through  the  apical  opening,  as 
sloughing  is  most  marked  at  the  apex,  and  the  apical  opening  in 
the  tooth  was  noticed  to  be  abnormally  large."  Many  practition- 
ers are  opposed  to  its  use  in  the  teeth  of  children.  More  than 
two  teeth  should  not  be  subjected  to  the  treatment  at  one  sitting, 
to  prevent  a  possible  chance  of  an  accidental  swallowing  of  a 
large  amount  of  the  poison. 

The  time  required  for  the  destruction  of  the  pulp  with  arsenic 
depends  on  many  circumstances.  In  the  young,  on  account  of 
the  great  vascularity  of  the  organ,  from  four  to  eight  hours  are 
usually  sufficient.  In  people  of  mature  age  it  is  best  to  leave 
the  application  in  situ  from  three  to  four  days.  This  allows  am- 
ple time  for  the  breaking  down  of  the  entire  pulp  and  its  rami- 
fications. Many  pulps  do  not,  however,  require  more  than  one 
or  two  days  to  succumb  to  the  effects  of  the  poison.  After  the 
arsenic  has  been  removed  it  is  well  to  apply  some  astringent  drug, 
such  as  tannic  acid  or  formaldehyd,  for  one  or  two  days,  which 
will  greatly  facilitate  the  ready  removal  of  the  pulp  in  toto.  Occa- 
sionally it  will  be  found  that,  on  the  removal  of  the  organ,  the 
apical  half  is  still  very  sensitive  to  the  touch.  If  it  becomes  neces- 
sary to  again  apply  arsenic  in  the  root  canal,  a  very  small  quan- 
tity of  the  paste  carried  on  the  end  of  a  barbed  broach,  which  is 
quickly  thrust  into  the  pulp  stump,  should  be  employed. 

The  following  important  factors  should  be  remembered  when  an 
arsenical  compound  is  used  for  the  purpose  of  destroying  the  pulp : 

1,  Only  the  smallest  possible  quantity  which  will  kill  the  pulp 
should  be  used. 

2,  Arsenic  should  never  be  applied  on  a  severely  aching  pulp. 


'Von  Metnitz:  Lehrbuch  der  Zahnheilkunde,  1903. 
*  Martin:  Dominion  Dental  Journal,  Vol.  XIV. 


244  PHARMACO-THERAPEUTICS 

3.  On  teeth  with  partially  absorbed  or  with  undeveloped  roots 
the  arsenical  paste  should  remain  only  from  four  to  eight  hours. 

4.  In  fully  developed  teeth  the  paste  may  remain  from  one  to 
four  days. 

5.  If  possible,  the  paste  should  be  applied  on  a  freely  exposed 
and  depleted  pulp. 

6.  The  retaining  seal  must  be  applied  without  pressure  and 
with  the  utmost  care. 

Toxicology. — If  arsenic  is  swallowed  in  an  overdose — 2  grains 
(0.12  Gm.)  are  known  to  have  killed  a  man— the  proper  anti- 
dotes should  be  promptly  administered.  Vomiting  should  be  in- 
duced by  the  finger,  the  feathery  part  of  a  quill,  or  by  an  emetic. 
The  ofificial  arsenic  antidote — freshly  prepared  ferric  hydrate  with 
magnesia — given  in  tablespoonful  doses  every  five  or  ten  minutes, 
or  dialysed  iron  followed  by  common  salt,  are  the  best  means  of 
chemically  neutralizing  the  poison. 

Local  toxic  effects  of  arsenic  in  the  mouth  are  most  frequently 
met  with  as  the  result  of  faulty  application  of  the  chemical  for 
dental  purposes.  Leakage  of  the  dressing  seal  is  responsible  in 
most  cases,  and  contact  of  the  mucous  membrane  with  instru- 
ments accidentally  carrying  small  particles  of  the  paste,  or  the 
unnoticed  squeezing  out  of  arsenic  resulting  from  pressure  ap- 
plied on  placing  the  retaining  stopping,  are  possible  factors.  The 
fact  that  arsenic  trioxid  is  odorless  and  tasteless  increases  this 
danger,  which  is  usually  recognized  only  after  the  mischief  is 
done.  A  number  of  cases  of  severe  forms  of  toxic  periostitis,  fol- 
lowed by  necrosis  of  the  alveolar  process,  and  consequent  loss  of 
one  or  more  teeth,  are  on  record. 

Pesoi  relates  a  ease  in  which  arsenic  applied  to  a  lower  left  first  molar 
caused  destruction  of  the  alveolar  process  and  gum  tissue  ranging  from  the 
first  bicuspid  to  the  second  molar.  Close  investigation  revealed  a  minute  per- 
foration of  the  distal  root.  Faughtz  reports  a  number  of  local  arsenical 
intoxications  resulting  from  the  application  of  a  rubber  dam  which  was  not 
washed  prior  to  its  application.  An  examination  developed  the  fact  that  the 
French  chalk  (soapstone)  used  for  preserving  the  dam  contained  sufficient 
calcium  arsenite  to  produce  the  affection.  Eecently  the  writer  observed  a 
series  of  cases  of  arsenical  dermatitis,  brought  about  by  the  same  cause.  The 
biologic  test  was  employed  and  it  revealed  the  presence  of  arsenic  in  three 


*  Peso:  Dental  Cosmos,  1903,  No.  5. 
*Faught:  Course  in  Dental  Pathology,  1885. 


CAUSTICS  245 

samples  of  rubber  dam  out  of  a  lot  of  ten.  The  same  samples  washed  in 
hot  water  and  soap  did  not  show  any  arsenical  reaction.  Powersi  described 
a  peculiar  arsenical  intoxication  which  resulted  in  the  loss  of  the  entire  lower 
denture.  The  local  poisoning  was  brought  about  by  frequently  cleansing  the 
teeth  with  yarn  which  had  been  dyed  with  colors  containing  arsenic.  In 
the  early  days  of  the  use  of  arsenic  in  dentistry  it  was  customary  with  many 
practitioners  to  place  a  permanent  filling  directly  over  the  arsenical  dress- 
ing without  making  an  effort  to  remove  the  pulp.  Usually  within  five  years 
one-half  of  the  teeth  treated  in  this  manner  were  lost  as  a  result  of  alveolar 
abscesses  or  of  toxic  pericementitis.  Coleman-Cunninghams  went  so  far  as 
to  recommend  a  weak  solution  of  arsenic  in  alcohol  and  oil  of  cloves  as  a 
preservative  of  pulp  stumps  left  in  inaccessible  root  canals,  such  treatment 
naturally  always  resulting  in  the  loss  of  the  tooth. 

Kiihns3  reports  a  cage  in  which  the  pulps  of  three  molars  died,  accom- 
panied by  pericemental  intoxication,  as  a  result  of  large  amalgam  fillings; 
an  analysis  of  the  amalgam  alloy  showed  that  it  was  made  from  impure 
metals  containing  arsenic.  The  latter  is  frequently  found  as  a  persistent 
impurity  in  commercial  tin  and  zinc.  Prolonged  retention  of  arsenic  in  a 
tooth  may  also  result  in  intoxication  of  the  pericementum.  Preiswerck*  has 
shown  that  arsenic  may  penetrate  through  the  dentinal  tubules  and  the  ce- 
mentum,  but  it  rarely  passes  through  the  entire  pulp  and  through  the  foramen. 
Dental  cements  containing  traces  of  arsenical  compounds  are  known  to  have 
destroyed  the  pulp.  It  has  been  argued  that  the  death  of  a  pulp  under  a 
cement  filling  is  the  result  of  the  irritating  action  of  free  phosphoric  acid 
or  of  zinc  chlorid.  While  this  may  be  correct,  it  is  nevertheless  proved  by 
chemic  analysis  that  the  powder  of  a  modern  so-called  silicate  cement  con- 
tained suflBcient  arsenic  to  be  the  cause  of  death  of  many  pulps.  Recent 
improvement  in  the  manufacture  of  this  cement  has  eliminated  the  presence 
of  the  arsenical  impurity. 

Boenings  presented  a  case  at  the  Garretson  Hospital  of  a  child  for  whom 
an  arsenical  application  had  been  made  to  a  deciduous  molar.  The  arsenic 
had  been  placed  in  the  tooth  for  the  purpose  of  devitalizing  the  pulp,  but 
the  supposed  pulp  did  not  exist.  The  arsenic  so  affected  the  surrounding 
tissue  that,  according  to  his  explanation,  paralysis  of  the  parts  ensued,  and 
a  general  breakdown  of  the  entire  soft  tissue  of  the  lower  jaw  followed,  in- 
volving some  of  the  hard  tissues.  Gangrene  set  in,  and  the  child's  life  was 
despaired  of.  By  heroic  methods  the  child  was  carried  along  between  life 
and  death  for  several  days  beyond  the  danger  line,  and  the  operation  per- 
formed later  on. 

In  all  cases  where  arsenical  poisoning  of  the  alveolar  tissues  is  suspected, 
and  where  proof  is  demanded  for  legal  testimony,  a  careful  differential  diag- 
nosis should  be  made  between  arsenical  necrosis  and  bacterial  infection,  dia- 

»  Powers:  Dental  Brief,  1902,  No.  11. 

*  Coleman-Cunningham:  In  Hollander,  Arzneimittellehre,   1890. 
•Kuhns:  Deutsche  Zalinarztliche  Wochenschrift,   1908. 

♦Preiswerck:  Osterreichisch-Ungarische  Vierteljahrsschrift  fiir  Zahnheilkunde,  1901. 
No.  2. 

•  Boening:  The  Stomatologist,  1905. 


246  PH  ARM  A  CO-THERAPEUTICS 

betic  gangrene,  or  arteriosclerotic  disturbances.  To  test  for  the  presence 
of  arsenic,  the  gathered  and  dried  necrotic  tissue  is  placed  in  a  bulb  tube 
with  a  dry  mixture  of  sodium  carbonate  and  potassium  cyanid.  The  bulbar 
end  is  heated  until  fusion  takes  place,  when,  if  arsenic  is  present,  a  metallic 
arsenic  mirror  will  appear  in  the  constricted  area  of  the  tube.  Another  test 
may  be  made  by  mixing  the  suspected  substances  with  sulphuric  acid  in  a 
test  tube.  To  3  cubic  centimeters  of  the  mixture  add  a  solution  of  iodin 
until  a  yellow  color  appears,  and  then  add  a  few  pieces  of  zinc.  After  in- 
serting a  loose  cotton  plug  into  the  tube,  cover  the  mouth  with  a  piece  of 
white   filter  paper,  the  center  of  which  has  been  moistened   with   a  drop   of 


Fig.  44. 

IvUxuriant   growth    of    Penicillium    brevicaule    on    sterile    bread    dough   charged    with   pulp 
tissue  destroyed  by  arsenic. 

concentrated  solution  of  silver  nitrate.  If  the  moistened  spot  becomes  yel- 
low immediately  or  after  some  time,  or  if  the  spot  becomes  black  or  brown 
at  its  periphery,  arsenic  is  surely  present. 

For  some  time  past  it  has  been  known  that  certain  molds  grown  upon 
media  containing  traces  of  arsenical  compounds  produce  volatile  arsins,  which 
are  characterized  by  a  pronounced  garlic-like  odor.  Gosioi  succeeded  in 
isolating  seven  varieties  of  molds,  of  which  Penicillium  brevicaule  (small, 
pencil-like,  short-haired)  possess  this  property  to  the  highest  degree.  Accord- 
ing to  Abel  and  Buttenbergs  1/64,000  of  a  grain   (0.000001  gm.)   of  arsenic 


*Gosio:  "Revista  d'igiene  e  sanita  publica,"  1892,  p.  201. 
'  Abel  u.   Buttenberg:   Zeitschrift  fiir  Hygiene,   1899,  p.   440. 


CAUSTICS 


247 


trioxid  represents  the  smallest  quantity  to  be  estimated  by  this  method.  The 
volatile  compounds  liberated  by  the  growth  of  the  mold  represent  a  mixture 
of  arsenated  hydrogen  and  arsenic  diethylate.  The  volatile  compounds  may 
be  decomposed  by  passing  them  through  a  Marsh  tube,  and  thereby  the 
typical  arsenical  spot  or  mirror  is  obtained.  The  great  advantage  of  this 
biologic  test  over  the  many  chemic  tests  consists  in  utilizing  the  poisoned 
tissues  directly  without  first  going  through  the  tedious  process  of  destroying 
their  organic  contents,  and  in  that  only  a  minute  quantity  of  the  suspected 
material  is  required. 

Methods  of  ProcedureA  A  ready  available  medium  for  the  rapid  growth 
of  the  mold  is  furnished  by  the  crumbs  of  white  or  Graham  bread;  the  crust 
must  not  be  used,  as  it  has  a  more  or  less  aromatic  odor.  The  bread  is  mixed 
with  sufficient  distilled  water  to  form  a  rather  stiff,  pasty  mass.  It  is  trans- 
ferred to  an  Erlenmeyer  flask  of  about  100  C.c.  capacity,  covering  its  bot- 


Fig.   45. 
Marsh  apparatus  for  detection   of  arsenic. 


torn  to  the  depth  of  about  1/4  inch.  Dry  bread  crumbs  are  now  sprinkled  over 
the  surface  to  absorb  the  surplus  water.  The  suspected  material  containing 
arsenic  in  powder  form,  or  cut  into  as  small  pieces  as  possible,  or  broken  up 
with  a  small  quantity  of  river  sand,  is  now  evenly  distributed  over  the  moist 
bread  surface.  The  flask  is  closed  with  a  cotton  plug  and  sterilized  in  a  steam 
autoclave  for  from  one-half  to  one  hour.  When  sufficiently  cooled,  the 
sterilized  material  is  inoculated  with  a  fresh  pure  culture  of  the  mold  by 
dropping  pieces  of  the  potato  upon  which  the  mold  has  grown  into  the  flask. 
The  flask  is  closed  with  a  tightly  fitting  cotton  plug  and  sealed  with  paraffin 
or  a  rubber  cap  drawn  over  the  plug.  The  mold  grows  best  at  body  tem- 
perature; if  an  incubator  is  not  available,  warm  room  temperature  will  an- 
swei:  the  purpose,  although  the   growth   is  somewhat  slow.     Usually,  within 


1  Prinz:  Dental  Cosmos,  1915,  p.  790. 


248  PHARMACO-THERAPEUTICS 

three  or  four  days,  a  luxuriant  growth  is  noticed  (see  Fig.  44),  and  incidentally 
with  its  development  the  looked-for  garlic  odor  becomes  more  and  more  pro- 
nounced. This  alliaceous  odor  can  be  detected  in  the  closed  flask  for  many 
we*^ks  after  the  experiment  is  made. 

An  arsenical  mirror  of  the  accumulated  arseneted  hydrogen  compounds 
is  readily  obtained  in  the  following  manner  (see  Fig.  45)  :  The  Erlenmeyer 
flask  is  fitted  with  a  rubber  stopper  having  two  perforations.  In  the  one 
opening  a  long-stemmed  separatory  funnel  is  pushed  so  as  to  nearly  touch 
the  growing  mold,  and  in  the  other  opening,  a  Marsh  tube,  i.e.,  a  glass  tube 
of  about  Ys  inch  in  diameter  and  bent  at  right  angles,  is  inserted.  The  long 
arm  at  its  center  part  is  drawn  out  to  a  narrow  tube  for  the  space  of  an 
inch  and  the  short  arm  must  pass  just  through  and  beyond  the  rubber  stop- 
per. The  long  arm  is  covered  with  a  piece  of  rubber  tubing  closed  by  a 
pinchcock.  The  closed  separatory  funnel  is  filled  with  mercury  and  the  Marsh 
tube  at  the  beginning  of  its  point  of  constriction  is  slightly  heated  over  a 
low  gas  flame.  The  stopcock  of  the  funnel  is  slowly  opened  and  the  ad- 
vancing mercury  displaces  the  arsenic  compounds  which  pass  over  the  heated 
part  of  the  glass  tubing.  Within  a  few  minutes  a  distinct  black  deposit,  i.e., 
metallic  arsenic,  is  observed  near  the  constricted  part  of  the  tube.  The  ex- 
periment must  be  conducted  in  a  room  free  from  draft  and  the  operator  is 
cautioned  not  to  inhale  the  highly  poisonous  arsenated  hydrogen. 

Arsenical  intoxication  of  the  gum  tissue  presents  in  its  early 
stages  all  the  phenomena  of  true  inflammation.  Later  the  sur- 
faces become  denuded  and  assume  a  raw  ham  color ;  the  veins  are 
distended,  the  border  of  the  infected  area  is  raised  and  shows  a 
loss  of  substance  in  the  depressed  center — the  typical  picture  of 
an  ulcer.  Usually  there  is  a  pronounced  metallic  taste  present  in 
the  mouth.  Arsenic  penetrates  very  deeply,  destroying  the  soft 
and  hard  tissues,  which  finally  results  in  true  necrosis.  In  the 
early  stages  the  affection  is  not  painful,  but,  as  soon  as  the  deeper 
structures  are  reached,  severe  pain  is  manifested. 

The  treatment  depends  on  the  severity  of  the  poisoning.  Simple 
intoxication  requires  the  immediate  removal  of  the  cause  and  mild 
antiseptic  mouth  washes.  If  necrosis  has  set  in,  the  affected 
parts  must  be  thoroughly  curetted  with  a  large  spoon  excavator; 
if  the  bone  has  sequestered,  it  must  be  removed.  Local  anesthesia 
is  usually  serviceable  for  such  work.  The  denuded  surface  is 
dusted  with  a  mixture  of  orthoform  and  corn  starch,  1  to  4.  If 
sequestration  of  the  alveolar  bone  continues,  the  application  of 
aromatic  sulphuric  or  diluted  sulphuric  acid  will  be  of  great  as- 
sistance in  detaching  the  dead  bone.  Rigid  antisepsis  is  of  prime 
importance.     A  bland  antiseptic  used  warm  and  at  frequent  in- 


CAUSTICS  249 

tervals  is  indicated  as  a  mouth  wash.  The  local  application  of 
dialyzed  iron  or  solution  of  iron  chlorid  as  arsenical  antidotes  is 
indicated  only  if  arsenic  is  present  in  substance  on  the  tissues; 
after  it  is  absorbed,  these  solutions  are  useless. 

Devitalizing  Compounds. 

IJ     Arsen.  trioxid.  gr.  xxx   (2.0  Gm.) 

Novocain.  gr.  xx  (1.3  Gm.) 

Petrolati.  q.  s.  to  make  a  paste. 

Add  a  small  amount  of  lampblack  to  color  the  paste. 

IJ     Arsen.  trioxid. 

Cocain.  hydrochlorid.  aa  gr.  xx   (1.3  Gm.) 

Menthol.  gr.  v   (0.3  Gm.) 

Glycerin.  q.  s.  to  make  a  i)aste. 

(Kirk.) 

ft     Arsen.  trioxid. 

Cocain.  hydrochlorid.  aa  gr.  xx   (1.3  Gm.) 

01.  caryophyl.  q.  s.  to  make  a  paste. 

(Miller.) 


Devitalizing  Fibers. 

R     Arsen.  trioxid.  gr.  v   (0.3  Gm.) 

Acid,  tannic.  gr.  ij    (0.12  Gm.) 

Morphin.  acetat.  gr.  x   (0.65  Gm.) 

Phenol,  liquefact.  q.  s.  to  make  a  thin  paste. 

Sig. :  Fine  cross-cut  absorbent  cotton  fiber  is  mixed  with 
this  paste  and  dried. 

(Flagg.) 

Devitalizing  Discs. 

ft     Arsen.  trioxid. 

Cocain.  hydrochlorid.  aa  equal  parts. 

01.  caryophyl.  q.  s.  to  make  a  tliin  paste. 

Sig.:  Cut  small  squares  (one  to  one  and  one-half  milli- 
meters) of  hard  white  blotting  paper,  saturate  with  the  paste, 
let  dry  for  a  few  hours  and  then  put  into  a  glass-stoppered 
bottle. 

(Bums.) 


250  PHARMACO-THERAPEUTICS 

HEMOSTATICS  AND  STYPTICS. 

Hemostatics  and  styptics  are  agents  which  arrest  the  flow  of 
blood  from  a  broken  vessel  wall — that  is,  hemorrhage.  At  pres- 
ent both  terms  are  used  analogously.  The  older  medical  lexicog- 
raphers restricted  the  term  "hemostatic"  (to  make  the  blood 
stand  still)  to  drugs  administered  internally  for  the  above  pur- 
poses, while  the  term  "styptic"  (to  tie  up)  was  reserved  for  ma- 
terials which  were  locally  applied. 

Remedies  which  are  applied  for  the  purpose  of  checking  hemor- 
rhage are  logically  divided  into: 

1.  Those  which  are  administered  internally  and  of  which  a 
general  action  on  the  circulation  is  expected. 

2.  Those  which  possess  a  definite  local  uction  when  applied 
on  the  broken  vessel  wall. 

The  action  of  the  true  hemostatics  is  expected  to  manifest  itself 
in  three  definite  ways: 

1.  To  coagulate  the  blood  at  the  point  of  its  exit  from  the 
broken  wall. 

2.  To  contract  the  vessel  locally. 

3.  To  reduce,  if  possible,  the  blood  pressure  within  the  region 
of  the  affected  part. 

The  seat  and  the  nature  of  the  hemorrhage  controls  largely 
the  means  of  its  treatment.  Hemorrhage  from  large  vessels  is 
always  controlled  preferably  by  mechanical  means — as  ligatures, 
torsion,  tamponing,  or  by  the  actual  cautery — while  small  ex- 
ternal bleedings  are  often  readily  checked  by  the  direct  applica- 
tion of  drugs  which  act  as  true  hemostatics.  Complete  immobi- 
lization of  the  part  and  perfect  rest  of  the  patient,  with  abstinence 
from  liquid  food,  especially  alcoholics,  is  of  marked  benefit. 

In  accordance  with  the  nature  of  their  action,  hemostatics  are 
closely  related  to  astringents,  protectives,  and  caustics.  For  the 
sake  of  convenience,  they  may  be  divided  as  follows: 

1.  Absorbents.  Purified  cotton,  styptic  cotton,  styptic  collo- 
dion, matico  leaves,  spunk,  penghawar  djambi,  the  old-fashioned 
use  of  cobweb,  and  many  indifferent  powders — starch,  talc,  pow- 
dered charcoal,  etc.  These  materials  form  a  glue-like  protective 
scab  over  the  broken  vessel  wall. 

2.  Caustics  and  astringents,     (a)     Metallic  salts — zinc  chlorid. 


HEMOSTATICS    AND   STYPTICS  251 

silver  nitrate,  potassium  permanganate,  iron  chlorid,  iron  sub- 
sulphate,  alum,  etc.,  and  all  acids  sufficiently  diluted  so  as  not  to 
cauterize;  concentrated  solution  of  hydrogen  dioxid  may  be 
classified  under  this  heading,  (b)  Tannic  acid,  or  its  various 
modifications, 

3.  Agents  wJiich  act  after  being  absorbed  into  tJie  circulation. 
Gelatin  solution,  calcium  chlorid,  calcium  lactate,  etc. 

4.  Agents  wJiicJi  act  on  tJie  vessels,  but  not  on  tJie  blood. 
The  alkaloid  of  the  suprarenal  capsule,  hydrastinin  hydrochlorid, 
stypticin,  styptol,  etc.  These  drugs  act  as  vasoconstrictors.  The 
smooth  muscular  coat  of  the  blood  vessels  is  constricted  by  the 
direct  action  of  drugs  in  two  ways — either  by  their  external  ap- 
plication, or  by  their  absorption  through  the  blood  current. 

Absorbents. 

Purified   (Absorbent)   Cotton;  Gossypium  Purificatum, 

U.  S.  P. 

The  hairs  of  the  seed  of  the  cotton  plant,  which  are  freed  from 
adhering  impurities  and  deprived  of  fatty  matter. 

Styptic   Cotton;   Gossypium   Stypticum. 

Absorbent  cotton  saturated  with  various  styptic  solutions — solu- 
tion of  salts  of  iron,  alum,  stypticin,  styptol,  etc. 

Styptic  Collodion;  Collodium  Stypticum. 

A  solution  of  tannic  acid,  20  parts,  in  diluted  collodion,  enough 
to  make  100  parts. 

Penghawar  Djambi;  Golden  Moss. 

The  long  silky,  yellowish,  very  soft  hairs  from  the  base  of 
strips  of  certain  tropical  ferns.  Penghawar  djambi  is  the 
Malayan  name  of  the  drug. 

Caustics  and  Astringents. 

Solution  of  Iron  Chlorid;  Liquor  Ferri  Chloridi,  U.  S.  P. 

An  aqueous  solution  of  ferric  chlorid,  containing  about  29  parts 
of  the  anhydrous  salt.     It  is  a   reddish-brown  liquid,   having  a 


252  PHARMACO-THERAPEUTICS 

faint  odor  of  hydrochloric  acid  and  an  acid,  strongly  styptic  taste. 
Average  dose,  lYo  minims   (0.1  C.c). 

Strong  Solution  of  Iron  Perchlorid;  Liquor  Ferri  Per- 
chloridi  fortis,  b.  p. 

It  is  a  solution  of  iron  chlorid  in  water,  containing  about  22.5 
per  cent  of  iron.  It  is  an  orange-brown  liquid,  with  a  strong  acid 
and  styptic  taste;  miscible  with  water  and  alcohol  in  all  propor- 
tions. 

Solution  of  Ferric  Subsulphate;  Liquor  Ferri  Subsul- 
phatis,  u.  s.  p. 

Monsel's  solution;  solution  of  iron  persulphate.  An  aqueous 
solution  of  basic  ferric  sulphate.  It  is  a  dark  reddish-brown 
liquid,  odorless  or  nearly  so,  of  an  acid,  strongly  styptic  taste  and 
an  acid  reaction.     Average  dose,  3  minims  (0.2  C.c). 

Iron  SuhsulpJiate;  Ferri  SuhsulpJiatis.  Monsel's  powder  or  salt; 
ferric  subsulphate  or  persulphate.  A  yellowish  hygroscopic  pow- 
der, readily  soluble  in  Avater  and  of. an  astringent,  styptic  taste. 
It  should  be  kept  in  well-stoppered  bottles.  Average  dose,  3  grains 
(0.15  Gm.). 

Ferripyrin;  Ferropyrin.  A  reddish  crystalline  powder,  con- 
taining 64  parts  antipyrin,  12  parts  iron,  and  24  parts  chlorin. 
It  is  readily  soluble  in  water.  It  is  applied  in  substance  or  in 
10  to  50  per  cent  solutions. 

The  above  mentioned  iron  preparations  should  not  be  used  in 
the  mouth  as  styptics;  they  are  caustic,  and  foiTn  a  dirty,  black 
coagulum  with  the  blood  and  the  lacerated  tissues. 

Alum;  Alumen,  U.  S.  P.,  B.  P.;  AlK  (SOJ2+12H2O;  Alu- 
minium AND  Potassium  Sulphate. 

Large  colorless  crystals,  without  odor,  and  having  a  sweetish 
and  strongly  astringent  taste.  Soluble  in  9  parts  of  water  at 
ordinary  temperature  or  in  0.3  parts  of  boiling  water.  Keadily 
soluble  in  warm  glycerin,  but  insoluble  in  alcohol.  Average  dose, 
7I/2  grains  (0.5  Gm.). 

Exsiccated  Alum;  Alum  Exsiccatum,  U.  S.  P.;  Alumen 

USTUM,  B.  P. 

Dried  or  burned  alum.    A  white  granular  powder,  without  odor, 


HEMOSTATICS   AND   STYPTICS  253 

having  a  sweetish,  astringent  taste.  It  is  soluble  in  about  20 
parts  of  water  at  ordinary  temperature  and  II/2  parts  of  boiling 
water.     It  readily  absorbs  moisture  from  the  air. 

Coagulen  (Koeher-Fonio),  a  grayish-brown  powder,  is  claimed 
to  represent  the  coagulating  substances  present  in  animal  blood. 
It  is  applied  in  a  10  per  cent  freshly  prepared  and  boiled  solu- 
tion in  distilled  water  on  a  tampon. 

Agents  Which  Act  After  Being  Absorbed  Into  the  Circulation. 
Gelatin;  Gelatinum,  U.  S.  P. 

The  purified  air-dried  product  of  the  hydrolysis  of  certain 
animal  tissues — as  skin,  ligaments,  and  bones — by  treatment  with 
boiling  water.  It  is  found  in  more  or  less  transparent,  solid,  thin 
sheets,  or  shredded;  it  is  odorless  and  colorless.  It  is  unalterable 
in  the  air  when  dry,  but  putrefies  very  rapidly  when  moist  or  in 
solution.  As  a  hemostatic  it  is  used  in  5  to  10  per  cent  solutions, 
using  physiologic  salt  solution  as  a  solvent.  They  must  be  heated 
so  as  to  liquefy  the  solution,  ready  for  use.  Extreme  care  is  neces- 
sary to  use  a  perfectly  sterile  solution;  cases  are  on  record  in 
which  tetanus  has  developed  as  a  sequence  of  an  infected  solution. 
Gelatin  contains  about  0.6  per  cent  calcium  salts,  and  it  is  prob- 
able that  this  latter  fact  has  much  to  do  with  the  ready  coagula- 
tion of  the  blood  when  gelatin  is  injected,  as  calcium  salts  are 
claimed  to  have  definite  influence  on  the  ready  formation  of  the 
blood  clot. 

The  injection  or  internal  administration  of  soluble  calcium 
salts,  especially  in  hemophilia,  has  been  tried  with  fair  results. 
Calcium  chlorid  and  calcium  lactate  are  serviceable  for  such  pur- 
poses. The  local  application  of  calcium  salts  with  the  hope  of 
acting  as  a  styptic  is  a  failure.  In  severe  dental  hemorrhage  the 
following  combination  may  be  tried: 

T^     Calcii  lact.  3  jss  (6.0  Gm.) 

Syrup,  aromatic.  fl3  j   (30  C.c.) 

Aquae  destill.  flS  iij   (90  C.c.) 

Sig. :     Tablespoonful  every  two  hours.    The  whole  quantity 
should  be  taken  within  twenty-four  hours. 

Coagulose  is  claimed  to  be  a  hemostatic  ferment.    It  is  employed 


254  PHARMACO-THERAPEUTICS 

in  a  freshly  prepared  solution  by  injecting  it  subeutaneously  into 
the  tissues. 

Agents  Which  Act  on  the  Vessels,  But  Not  on  the  Blood. 

Solution  of  Epinephrin  Chlorid,  1 :1,000. 

This  solution  is  used  undiluted  for  external  application,  or  by 
means  of  intra-parenchymatous  injections,  1 :10,000  or  1 :12,000. 
As  a  hemostatic  for  dental  purposes  it  is  of  questionable  value, 
but  as  an  addition  to  local  anesthetics  on  account  of  its  vaso-con- 
strictor  action  it  is  very  important. 

Hydrastinin  Hydrochlorid  ;  Hydrastinin^  Hydrochloridum, 

U.  S.  P. 

A  light-yellowish  crystalline  powder,  odorless,  and  of  a  very 
bitter  taste,  prepared  from  an  artificial  alkaloid  derived  from 
hydrastin;  the  latter  is  obtained  from  golden  seal,  hydrastis  cana- 
densis, U.  S.  P.,  B.  P.  It  is  very  soluble  in  cold  and  hot  water. 
Average  dose,  I/2  grain  (0.03  Gm.). 

Stypticin  ;  Cotarnin  Hydrochlorid,  U.  S.  P. 

A  product  of  oxidation  of  narcotin.  A  lemon-yellow  powder 
or  crystals,  having  a  bitter  taste.  It  is  soluble  in  water  and  alco- 
hol. Externally  it  is  applied  in  substance  or  in  concentrated  solu- 
tions, and  internally  in  tablets  or  in  gelatin  capsules.  Average 
dose,  %  grain  (0.04  Gm.). 

Styptol;  Cotarnin  Phthalate. 

A  lemon-yellow,  very  fine  crystalline  powder,  which  is  very 
readily  soluble  in  water.  It  is  applied  externally  in  substance  or 
in  concentrated  solution,  and  internally  in  sugar-coated  tablets 
or  gelatin  capsules.    Average  dose,  %  grain  (0.04  Gm.). 

Ergot  in  the  form  of  the  fluidextract,  the  solid  extract,  or  the 
various  alkaloids,  and  many  other  forms  is  recommended  as  an 
internal  hemostatic.  It  is  especially  applicable  in  hemorrhage  of 
the  uterus. 

Potassium  Permanganate  in  5  to  10  per  cent  solutions  acts  as 
a  strong  styptic.  A  paste  made  of  the  salt  with  charcoal  and 
vaselin  is  known  as  styptogan. 


PROTECTIVES,    DEMULCENTS,    AND   EMOLLIENTS  255 

Zinc  Chlorid  in  1  to  5  per  cent  solutions  is  a  powerful  styptic, 
which  may  act  even  through  the  vessel  wall.  Its  application  is 
painful. 

Lemon  Juice  and  Ordinary  Vinegar  are  frequently  employed 
by  the  laity  as  styptics. 

Chromic  Trioxid  in  10  to  50  per  cent  aqueous  solutions  acts  as 
a  powerful  styptic.     Its  application  requires  great  care. 

Hydrogen  Dioxid  in  3  to  5  per  cent  solutions  is  a  mild  styptic ; 
the  25  per  cent  ethereal  solution,  pyrozon,  and  the  30  per  cent 
aqueous  solution,  perhydrol,  are  very  powerful  styptics.  The 
latter  solutions  must  be  used  with  great  caution. 

Tannic  Acid,  which  is  the  active  constituent  of  all  vegetable 
astringents,  will  quickly  coagulate  the  blood  if  applied  in  sub- 
stance or  in  concentrated  solution.  For  smaller  hemorrhage  the 
glycerite  of  tannic  acid  is  useful.  Since  the  introduction  of  stypti- 
ein  and  styptol,  tannic  acid  has  lost  much  of  its  repute  as  a  hemo- 
static, 

PROTECTIVES,  DEMULCENTS,  AND  EMOLLIENTS. 

Protectives  are  agents  which  are  employed  for  the  purpose  of 
mechanically  covering  sensitive,  wounded,  diseased,  or  otherwise 
defective  body  surfaces,  including  the  mouth,  against  external 
insults. 

Demulcents,  sometimes  referred  to  as  vehicles,  are  usually  col- 
loidal, oily,  or  albuminous  substances,  which  are  employed  for  the 
purpose  of  mechanically  covering  sensitive,  wounded,  diseased,  or 
otherwise  defective  mucous  surfaces  against  further  insults.  They 
are  closely  related  to  protectives  and  emollients.  Demulcents  are 
often  given  internally  to  envelop  nauseous,  ill-tasting  medicines, 
or  to  give  body  to  watery  solutions  of  drugs  which  are  used  in 
large  quantities;  they  retard  the  absorption  of  drugs.  Oleo-resins, 
balsams,  oils,  and  other  substances  insoluble  in  water  are  usually 
administered  in  aqueous  mixtures  in  which  the  minute  droplets 
are  held  in  suspension  in  the  form  of  an  emulsion  by  means  of 
acacia  or  tragaeanth. 

Emollients,  sometimes  referred  to  as  protectives,  are  bland,  oily 
substances  which  are  employed  externally  to  protect  the  skin,  the 
surfaces  of  a  wound,  or  the  otherwise  denuded  epidermis  from 
irritation   bv   the   air   or   other   mechanical   disturbances.     Their 


256  PHARMACO-THERAPEUTICS 

action  is  purely  local ;  they  render  the  skin  soft  and  more  pliable. 
A  drug,  when  applied  to  the  skin,  is  more  quickly  absorbed  when 
dissolved  in  an  emollient,  as  it  readily  mixes  with  the  sebaceous 
matter  which  covers  the  external  epithelium.  Animal,  vegetable, 
and,  recently,  mineral  fats  and  oils  are  used  for  such  purposes. 
Simple  mechanical  protectives,  which  have  no  medicinal  action, 
are  also  classified  as  emollients. 

Rubber;  Elastica,  U.  S.  P.;  Caoutchouc;  India  Rubber; 
Caoutchouc,  F.  ;  Kautschuk,  G. 

It  is  the  prepared  milk  juice  of  several  species  of  the  family 
EuplwrMacece,  and  is  commercially  known  as  Para  rubber.  Rub- 
ber forms  the  base  of  many  important  preparations.  When  mixed 
with  sulphur  and  subjected  to  a  high  heat  under  pressure,  it  is 
known  as  vulcanized  rubber  or  vulcanite.  Vulcanite  is  largely 
used  in  the  arts,  in  medicine,  and  in  dentistry  in  the  form  of 
bandages,  drainage  tubes,  catheters,  bags,  instruments,  etc.  It 
is  an  important  adjunct  to  surgical  practice,  while  dentistry  em- 
ploys vulcanite  chiefly  as  a  cheap  and  reliable  base  for  artificial 
dentures  and  in  the  form  of  rubber  dam  (coffer  dam)  as  a  means 
of  excluding  moisture  from  the  teeth  during  operations.  Para 
rubber  is  also  largely  used  for  the  preparation  of  adhesive  and 
other  plasters. 

Gutta-Percha ;  Gutta-Percha.  B,  P.:  Gutta-Percha.  F..  G. 

It  is  the  concrete  milk  juice  of  Palaqiiium  gutta  and  allied 
plants.  The  purified  gutta-percha  is  a  white,  odorless,  and  taste- 
less inert  mass,  which  readily  softens  by  the  application  of  heat. 
It  forms  the  base  of  many  important  preparations — tooth  filling 
materials,  surgical  splints,  and  other  appliances  of  a  similar  na- 
ture. A  10  per  cent  solution  of  purified  gutta-percha  in  chloro- 
form is  known  as  traumaticin,  and  is  used  in  Europe  as  a  substitute 
for  collodion;  it  forms  an  excellent  protective  seal  over  small 
wounds  in  the  mouth.  In  the  form  of  chloro-percha  it  is  largely 
used  as  a  root  canal  filling. 

Many  resins — as  sandarac,  mastic,  copal,  dammar,  shellac,  rosin, 
etc. — in  alcohol  or  ethereal  solutions  are  employed  in  dentistry 
for  mechanical  and  surgical  purposes. 


PROTECTIVES,    DEMULCENTS,    AND   EMOLLIENTS  257 

Collodion  ;  Collodium,  U.  S.  P.,  B.  P. ;  Collodion,  F.  ; 

COLLODIUM,  G. 

It  is  a  solution  of  pyroxylin  (colloxylin,  gun-cotton)  in  a  mix- 
ture of  ether  and  alcohol.  A  very  concentrated  collodion  in  dry 
form  is  known  as  colloidin.  Collodion  should  be  kept  in  a  well- 
corked  bottle,  protected  from  light  and  fire. 

Flexible  Collodion;  Collodium  Flexile,  U.  S.  P.,  B.  P.  It  is 
ordinary  collodion  with  the  addition  of  small  quantities  of  Cana- 
dian turpentine  and  castor  oil  to  make  it  more  flexible. 

Compound  Tincture  of  Benzoin;  Tincfura  Benzoini  Composita, 
U.  S.  P.,  B.  P.;  Turlington's  Balsam;  Friars'  Balsam;  Jesuits' 
Drops.  It  is  an  alcoholic  solution  of  benzoin,  aloes,  storax,  and 
balsam  of  Tolu. 

Glycerin;  Glycerinum,  U.  S.  P.,  B.  P.,  Glycerol. 

A  liquid  obtained  by  the  decomposition  of  vegetable  and 
animal  fats,  or  fixed  oils,  and  containing  not  less  than  95  per  cent 
of  absolute  glycerin,  a  triatomic  alcohol.  It  is  a  clear,  colorless 
liquid,  of  a  thick,  syrupy  consistence,  oily  to  the  touch,  with  a 
sweet  taste  and  no  odor.  It  is  soluble  in  all  proportions  in  water 
and  alcohol.  It  is  principally  employed  as  a  solvent  for  other 
drugs,  the  preparations  being  known  as  glycerites  (U.  S.  P.)  and 
glycerins  (B.  P.).     Average  dose:  1  fluidram  (4  C.c.) 

Paraffin  ;  Paraffinum,  U.  S.  P. ;  Paraffinum  Durum,  B.  P. ; 
Paraffine,  F.  ;  Paraffin,  G. 

A  mixture  of  solid  hydrocarbons,  without  odor  and  taste.  It  is 
soluble  in  ether,  volatile  oils,  etc.,  but  insoluble  in  water  and 
alcohol.    It  melts  at  125°  to  135°  F.  (51°  to  57°  C). 

Petrolatum  ;   Petrolatum,  U.   S.   P. ;   Petrolatum  Album, 
U.  S.  P. ;  Paraffinum  Molle,  B.  P. ;  Vaselin. 

These  various  soft  petrolates  have  the  consistency  of  an  oint- 
ment. They  are  yellow  or  white  in  color,  tasteless,  and  readily 
liquefy  a  few  degrees  above  body  temperature.  They  are  prin- 
cipally used  as  ointment  bases. 


258  pharmaco -therapeutics 

Solution  of  Sodium  Silicate;  Liquor  Sodii  Silicatis;  Liquid  or 
Soluble  Glass;  Liquid  Silex;  Silicate  de  Soude  Liquide,  F. ; 
Flussiges  Wasserglas,  G. 

It  is  a  yellowish,  viscid  liquid,  having  a  sharp,  alkaline  taste; 
it*  is  miseible  in  all  proportions  with  water. 

Acacia;  Acacia,  U.  S.  P.;  Acacia  Gummi,  B.  P. 

Gum  arable  is  a  gummy  exudate  obtained  from  Acacia  Senegal 
and  other  species  of  acacia,  and  consists  of  the  potassium,  magne- 
sium, and  calcium  salts  of  a  weakly  acid  substance  known  as 
arabin,  or  arabimic  acid.  It  appears  in  whitish,  translucent, 
roundish  tears;  it  is  insoluble  in  alcohol,  but  slowly  soluble  in 
equal  parts  of  water,  and  is  used  largeh*  as  a  vehicle  for  other 
drugs. 

Mucilage  of  Acacia;  Mucilago  Acacias,  U.  S.  P.,  B.  P.  It  con- 
tains about  1  part  of  acacia  dissolved  in  2  parts  of  water.  Average 
dose,  4  fluidrams  (16  C.c). 

Tragacanth;  Tragacantha,  U.  S.  P.,  B.  P. 

A  gummy  exudation  from  various  species  of  Astragulus.  It 
appears  in  ribbon-shaped  bands  or  in  irregular  pieces  of  a  whitish 
color,  somewhat  translucent.  Tragacanth,  when  treated  with  50 
parts  of  water,  swells  and  gradually  forms  a  cloud}',  gelatinous 
jelly.  It  is  chiefly  used  as  a  binding  agent  in  pills,  troaches,  etc. 
Powdered  tragacanth  is  usually  the  principal  component  of  the 
many  powders  which  are  advocated  for  the  purpose  of  making 
an  artificial  denture  "stick"  to  the  mucous  surfaces  of  the  mouth. 
A  mucilage,  a  glj'^cerite,  and  a  compound  powder  of  tragacanth 
are  also  emploj^ed. 

Sassafras  Pith;  Sassafras  Medulla,  U.  S.  P. ;  Slippery  Elm  Bark; 
Ulmus,  U.  S.  P.;  Root  of  Altlioea  {Marslimallow) ;  AltJiaea,  U.  S. 
P.;  Linseed  or  Flaxseed;  Limim,  U.  S.  P.,  B.  P.;  Triticum  (CoucJi 
Grass);  Triticum,  V.  S.  P.;  Starcli;  Amylum,  U.  S.  P.,  B.  P.; 
Licorice  Root;  GlycyrrJiiza,  U.  S.  P.,  B.  P. ;  IrisJi  Moss  or  Car- 
ragheen; Chondrus,  U.  S.  P.  These  various  drugs  and  many  of 
their  preparations  are  used  as  demulcents  in  general  medicine. 

Exsiccated  Calcium  Sulphate;  Calcii  Sulphus  Exsiccatus,  U. 
S.  P. ;  CaS04 ;  Dried  Gypsum  ;  Plaster  of  Paris  ;  Platre,  F.  ; 
GiPS,  G. 
A  fine  white  powder,  without  odor  and  taste.    When  mixed  with 


PROTECTIVES,    DEMULCENTS,    AND   EMOLLIENTS  259 

half  its  own  weight  of  water,  it  forms  a  smooth,  cohesive  paste, 
which  rapidly  hardens.  It  should  be  kept  in  well-closed  vessels 
and  carefully  protected  from  moisture.  A  pinch  of  potassium  sul- 
phate, sodium  ehlorid,  or  alum  dissolved  in  the  water  before  the 
plaster  of  Paris  is  added  hastens  the  setting,  and,  to  some  extent, 
prevents  expansion.  The  setting  of  plaster  of  Paris  is  much  re- 
tarded by  adding  2  to  4  per  cent  of  powdered  marshmallow  root. 
A  cold,  saturated  solution  of  sodium  hyposulphite  will  disintegrate 
"set"  plaster  of  Paris. 

Plasters — adhesive,  fatty,  or  resinous  compounds,  spread  on 
textile  fibers,  leather,  muslin,  etc. — are  used  to  hold  the  edges  of 
small  wounds  together  or  to  immobilize  parts  of  the  body.  Their 
action  is  purely  mechanical. 

Dextrin,  gelatin,  tragaeanth,  starch,  lycopodium,  and  many  in- 
organic compounds — talc,  chalk,  zinc  oxid,  magnesium  oxid,  etc. 
— are  also  largely  used  as  protectives,  either  single  or  mixed  to 
a  paste  with  olive  oil,  petrolatum,  etc. 

Carbolized  Rosin. 


Phenol  c 

rystals                           3  ii 

(8  Gm.) 

Bosin 

3ij 

(8  Gm.) 

Chlorofo: 

rm                                   fl3  j 

ss   (6  C.c.) 

ELLULO-ACETON     (  KOWARSK  Y  ' 

s  Paste). 

Celluloid 

3  iv 

(16  Gm.) 

Aceton 

113  X   (40  Co.) 

Chloro-Percha. 

Gutta-pe 

rcha  base  plate           3  ij 

(8  Gm.) 

Chloroform                                  a  suflScient  quantity 

Sandarac  Varnish. 

Sandarac                                     3  j 

(4  Gm.) 

Eosin,  li 

ght  colored                   3  j 

(4  Gm.) 

Alcohol 

fl3  ij   (8  C.c.) 

Shellac  Varnish. 

Shellac 

3  ij 

(8  Gm.) 

Alcohol 

fl3  ^ 

vi  (24  C.c.) 

260  pharmaco-therapeutics 

Dentist's  Hand  Cream. 

Tincture  of  benzoin  3  ss  (2  C.c.) 

Borax  3  i   (4  Gm.) 

Lanolin  5  ss  (15  Gm.) 

Glycerin  3  i  (30  C.c.) 

Petrolatum  5  iss  (45  Gm.) 


Steresol  (Antiseptic  Wound  Varnish). 

SheUac  5  jx  (270  Gm.) 

Gum    benzoin  3  ijss  (10  Gm.) 

Balsam  of  Tolu  3  ijss  (10  Gm.) 

Phenol  5  iij  %  (100  Gm.) 

Oil  of  cinnamon  3  jss   (6  C.c.) 

Saccharin  3  iss  (6  Gm.) 
Alcohol,  enough  to   make       flS  xxxij   (1000  C.c.) 

Simplified  Wound  Varnish.     (Masticol.) 

Gum  mastic  3  v  (20  Gm.) 

Aceton  3  xijss  (50  C.c.) 

Linseed  oil  gtt.  xx   (20  drops) 


IRRITANTS  AND  COUNTERIRRITANTS. 

The  local  application  of  irritants  and  counterirritants  plays  an 
important  part  in  the  clinical  practice  of  dentistry.  Depending 
on  their  intensity  of  action,  irritants  may  be  classed  as  rubefa- 
cients, vesicants,  and  pustulants.  Rubefacients  (reddening  the 
skin)  produce  only  mild  symptoms  of  irritation  in  the  form  of 
congestion  and  redness,  while  vesicants  (drawing  blisters)  and 
pustulants  (forming  pustules)  are  very  powerful  in  their  action. 
According  to  the  conception  of  the  older  practitioners,  irritants 
were  employed  for  the  purpose  of  depleting  the  ''malignant  hu- 
mors" from  the  diseased  part  into  the  immediate  neighborhood. 
Such  irritants  were  known  as  derivants,  while  revulsives  were  used 
to  disseminate  these  humors  into  the  farther  situated  parts.  In 
many  instances  irritants  are  applied  to  the  healthy  tissue  some- 
what distant  from  the  primary  seat  of  disturbance,  with  the  inten- 
tion of  diverting  the  deep-seated  congestion  into  a  new  direction, 
or,  as  our  forefathers  expressed  it,  "to  leave  a  way  for  the  escape 
of  the  humors."  Proof  for  this  supposition  has  never  been  fur- 
nished.   Medicaments  applied  for  these  purposes  are  known  as 


IRRITANTS    AND    COUNTER   IRRITANTS  261 

counterirritants.  If  strong  irritants  are  applied  to  a  circumscribed 
area  of  tissue,  an  exudation  of  small  globules  of  serum  occurs ;  the 
latter  soon  coalesce  and  raise  the  epidermis  of  the  true  skin,  there- 
by forming  a  blister.  Blistering  agents  are  known  as  vesicants  or 
as  epispastics.  If  the  drugs  applied  as  irritants  can  not  pass 
through  the  horny  epidermis,  they  produce  small  exanthematous 
abscesses,  which  may  coalesce  and  form  a  large  ulcer.  Drugs  used 
for  such  purposes  are  referred  to  as  pustulants  or  suppurants. 
This  heroic  form  of  medication  is  rarely  employed  at  present;  it 
was  quite  common  with  the  practitioners  of  bygone  days.  Croton 
oil,  tartar  emetic,  veratin,  and  mezereum  bark  are  a  few  examples 
of  drugs  used  as  pustulants. 

At  present  it  is  generally  recognized  that  the  milder  irritants 
produce  the  preliminary  stages  of  inflammation — hyperemia.  An 
increased  influx  and  a  retarded  afflux  of  blood  in  the  irritated 
tissue  is  the  sequence  of  the  irritation,  and  not,  as  it  has  been 
generally  supposed,  a  diversion  of  the  blood  stream.  Depending 
on  the  nature  of  the  irritant,  the  congestion  may  be  superficial,  or 
it  may  reach  to  quite  a  depth.  Hyperemia,  in  the  sense  of  Bier 
(see  Artificial  Hyperemia),  is  one  of  the  most  important  functions 
which  nature  possesses  in  overcoming  morbid  processes.  Tissues 
which  are  richly  supplied  with  blood  possess  a  very  pronounced 
restorative  power,  and  there  is  no  doubt  that  artificial  hyperemia 
exercises  a  distinct  beneficial  influence  on  the  reparative  processes. 
This  is  partially  the  reason  why  wounds  in  the  oral  cavity  heal 
so  much  quicker  than  in  other  parts  of  the  body.  Pain  in  deep- 
seated  structures  is  often  mitigated  by  applying  an  irritant.  By 
counterirritation  of  a  sensory  surface  located  somewhat  distant 
from  the  primary  seat  of  irritation,  we  may  be  able  to  divert  the 
pain  to  this  newly  excited  focus.  Such  applications  are  usually 
employed  in  the  many  forms  of  ill-defined  pericemental  disturb- 
ances. Some  of  the  substances  employed  as  irritants  act  by  re- 
flex action — that  is,  after  their  primary  action  they  produce  so- 
called  reflexes,  which  have  a  beneficial  influence  on  pathologic 
disturbances. 

It  should  be  remembered  that  the  same  irritant  produces  dif- 
ferent effects  on  tissues  of  different  resistance.  The  more  delicate 
mucous  membrane  of  the  mouth  requires  naturally  less  severe  ir- 
ritation to  produce  definite  results  than  the  thick  and  horny  layers 
of  the  skin. 


262  PHARMACO-THERAPEUTICS 

Counterirritation  is  sometimes  referred  to  as  depletion.  De- 
pletives (to  empty)  are  means  which  were  very  frequently  used 
in  former  years  for  the  purpose  of  locally  abstracting  blood  or 
serum  from  the  tissues  in  general  or  from  the  point  of  disease. 
Dry  and  wet  cupping,  scarification,  and  leeching  w^ere  the  usual 
methods  employed  for  such  purposes.  Local  depletion  by  physical 
means  is  rarely  practiced  at  present.  General  depletion  of  the  sys- 
tem by  artificially  increased  perspiration  or  by  abstracting  fluids 
from  the  body  through  the  bowel  by  salines  or  hydragogues  are 
referred  to  under  Cathartics  and  Diaphoretics. 

lodin  in  aqueous  or  in  alcoholic  solution  occupies  an  important 
place  among  the  irritants.  It  possesses  a  powerful  and  penetrat- 
ing action.  Alcohol,  chloroform,  the  essential  oils,  and  mustard 
are  also  favorite  irritants,  while  cantharides  is  a  typical  representa- 
tive of  a  blistering  agent.  Ammonia,  well  diluted,  in  the  form  of 
a  liniment  constitutes  an  important  irritant  in  popular  medica- 
tion. 

lODIN ;  lODUM,  U.  S.  P.,  B.  P.  ;  I ;  lODE,  F.  ;  JOD,  G. 

Source  and  Character. — lodin  (from  the  Greek  ioeides,  vio- 
let-colored) was  discovered  by  Courtois  in  1811,  and  named  iodin 
by  Gay-Lussac  on  account  of  its  violet-colored  vapors.  Iodin  is 
prepared  from  crude  iodin,  which  is  obtained  from  kelp,  but 
principally  from  the  mother  liquors  of  Chile  saltpeter  of  South 
America.  It  forms  heavy,  bluish-black,  friable  crystals,  having  a 
characteristic  odor  and  a  sharp  and  acrid  taste.  It  is  soluble  in 
5,000  parts  of  water,  10  parts  of  alcohol,  freely  soluble  in  ether, 
chloroform,  and  in  the  solution  of  the  iodids  of  the  alkalies.  Its 
alcoholic  solution  has  a  reddish-brown  color,  while,  when  dissolved 
in  chloroform  or  carbon  disulphid,  it  exhibits  a  violet  tint.  It 
volatilizes  at  ordinary  temperature  and  fuses  at  about  239°  F. 
(115°  C).  It  is  incompatible  with  starch,  tannin,  vegetable  colors, 
etc. 

Average  Dose. — Yiq  grain  (0.005  Gm.). 

Medical  Properties. — Antiseptic,  caustic,  and  alterative. 

Therapeutics. — Iodin,  in  concentrated  solution,  acts  as  a  caus- 
tic; in  diluted  solution,  applied  locally,  it  produces  only  irritant 
effects.  Iodin  has  a  peculiar  action  on  the  vessel  walls,  as  it  in- 
creases their  penetrability.  It  produces  typical  fibrinous  inflam- 
mation of  the  serous  membranes.     After  the  destruction  of  their 


IRRITANTS    AND    COUNTER   IRRITANTS  263 

epithelial  coat,  these  serous  membranes  show  a  pronounced  ten- 
dency to  stick  together  and  to  heal  by  first  intention.  For  this 
reason  iodin  is  successfully  employed  in  the  treatment  of  fistulous 
tracts,  etc.  Painted  on  the  skin,  iodin  quickly  penetrates  into 
the  structures,  and  produces  sensible  irritation,  thereby  reliev- 
ing pain  which  may  be  present  in  the  deep-seated  tissues.  In- 
cidentally it  enlarges  the  walls  of  the  various  vessels,  promotes 
absorption,  and  by  reflex  action  produces  venous  hyperemia,  which 
involves  all  the  tissues  within  the  affected  area.  The  favorable  in- 
fluence of  this  artiflcially  produced  hyperemia  on  the  diseased  tis- 
sues is  more  fully  discussed  under  Physical  Therapeutics.  (See 
Artificial  Hyperemia.)  Iodin  is  very  freely  employed  in  an  al- 
coholic solution  (tincture  of  iodin),  and  as  the  milder  acting 
Lugol's  solution.  In  using  the  tincture  of  iodin  the  alcoholic  com- 
ponent of  the  latter  must  be  accredited  with  a  certain  share  of  its 
action. 

To  promote  the  more  ready  absorption  of  iodin,  various  solu- 
tions have  been  recently  introduced.  lodipin,  an  iodized  sesame 
oil,  containing  respectively  10  and  25  per  cent  of  iodin,  and 
iothion,  a  glycerinated  solution,  containing  77  per  cent  of  iodin, 
are  the  more  important  representatives  of  this  group.  Both  prep- 
arations are  almost  colorless  and  odorless,  and  are  used  as  sub- 
stitutes for  the  tincture  for  external  and  internal  purposes. 

Iodin,  per  se  or  in  solution,  is  very  destructive  to  metallic  in- 
struments. The  top  of  the  ground-glass  cover  office  bottle  con- 
taining the  iodin  solution  should  be  coated  with  a  thin  lining  of 
vaselin  as  an  additional  protection. 

Preparations. — 

Tincture  of  Iodin;  Tinctura  lodi,  U.  S.  P.,  B.  P.  It  contains 
7  per  cent  (2.5  per  cent,  B.  P.)  of  iodin  dissolved  in  alcohol.  The 
U.  S.  P.  tincture  contains  in  addition  5  per  cent  of  potassium  iodin, 
which  increases  its  therapeutic  effect  and  stability. 

Compound  Solution  of  Iodin;  Liquor  lodi  Compositus,  U.  S.  P. ; 
Lugol's  Solution.  It  contains  5  per  cent  of  iodin  dissolved  in  a 
10  per  cent  aqueous  solution  of  potassium  iodid. 

Iodin  Liniment;  Liquor  lodi  Fortis,  B.  P.  It  contains  about 
14  per  cent  of  iodin. 

Therapeutics. — Tincture  of  iodin  is  universally  employed  as  a 
counterirritant   in   pericemental   disturbances.      Its   beneficial   in- 


264  PHARMACO-THERAPEUTICS 

fluence  is  based  on  three  principal  functions  of  iodin — to  act  as  a 
derivant  by  sensory  irritation,  to  produce  artificial  hyperemia,  and 
to  promote  absorption.  Its  antiseptic  properties  are  of  less  im- 
portance in  this  connection.  If  a  definite  iodin  action  is  desired 
in  the  mouth,  the  ordinary  tincture  is  not  well  suited  for  this  pur- 
pose. Its  alcoholic  component  causes  superficial  coagulation  of 
the  delicate  mucous  membrane,  and  in  reality  very  little  iodin  is 
absorbed  from  this  weak  solution.  If  the  tincture  is  repeatedly 
applied  at  short  intervals,  the  caustic  effect  of  the  alcohol  destroys 
the  mucous  lining,  and  a  painful  excoriated  surface  is  the  result. 
The  irritating  effect  of  the  alcohol  is  probably  as  much  responsible 
for  the  apparent  results  attributed  to  the  tincture  as  its  iodin  com- 
ponent. Liquid  iodin  preparation  for  dental  purposes  should  be 
concentrated  solutions  in  water,  preferably  in  the  form  of  Talbot's 
iodo-glycerol.  (See  page  206.)  A  colorless  tincture  of  iodin  is 
occasionally  demanded ;  ammonia  water  added  to  the  tincture  will 
quickly  destroy  its  color.  If  higher  concentrated  iodin  solutions 
are  wanted,  Carson's  or  Churchill's  iodin  paint  is  serviceable, 
but  these  compounds  should  not  be  used  indiscriminately  on  the 
mucous  surfaces  of  the  mouth. 

Tincture  of  iodin  applied  to  the  mucous  membranes  of  the  mouth 
is  not  as  harmless  a  remedy  as  is  presumed  by  some  practi- 
tioners. The  routine  advice  to  patients  to  "paint  with  iodin"  in 
cases  of  pericemental  trouble  is  wholly  unwarranted.  From  the 
ready  absorption  of  iodin  applied  to  the  mucous  membrane  of  the 
mouth  for  a  certain  length  of  time,  edema  of  the  glottis  and,  on 
rare  occasions,  iodism  has  resulted.  Witzel  reports  one  case  which 
ended  fatally,  and  a  few  others  in  which  the  lives  of  the  patients 
had  been  endangered  by  the  careless  use  of  this  powerful  drug. 

If  an  oily  solution  of  an  iodin  preparation  is  needed,  aristol  oil 
will  answer  the  purpose  well.  It  may  be  prepared  by  sterilizing 
214,  ounces  (70  Gm.)  of  sesame  oil  in  a  flask  heated  to  302°  F. 
(150°  C),  and  adding  to  the  cold  oil  2  drams  (8  Gm.)  of  aristol. 
Set  aside  undisturbed  for  half  an  hour.  During  the  next  ten 
hours  the  liquid  is  repeatedly  shaken,  and  after  three  or  four  days 
the  solution  is  siphoned  off  from  the  undissolved  portion  into  a 
sterilized  bottle.  Aristol  or  its  solution  should  never  be  heated; 
heat  will  readilj'  decompose  it. 


irritants  and  counter  irritants  265 

Talbot  's  Iodo-Glycerol. 

Zinc   iodid.  3  iij    (12  Gm.) 

Water  fl3  ij   (8  C.c.) 

lodin  3  V   (20  Gm.) 

Glycerin  fl3  x  (40  C.c.) 

Younger 's  Iodin  Solution. 


Zinc  sulphate  3  v  (20  Gm.) 

Distilled  water  fl3  iii  (12  C.c.) 

n. 

Potassium  iodid  3  ii   (8  Gm.) 

Distilled  water  flB  j   (30  C.c.) 

Iodid  crystals,  enough  to  make  a  saturated  solution. 

Mix  equal  parts  of  Solution  I  and  II  and  keep  for  2  weeks 
or  until  the  freshly  formed  potassium  sulphate  has  crystal- 
lized out.  Decant  the  clear,  supernatant  solution  of  zinc 
iodid. 

Carson's  Iodin  Paint. 

Iodin  3  j    (4  Gm.) 

Alcohol  flS  j    (30  C.c.) 

Churchill's  Iodin  Caustic. 

Iodin  '  3  3    (4  Gm.) 

Potassium  iodid  3  ij    (8  Gm.) 

Water  fl3  iv  (16  C.c.) 

The  solution  should  be  kept  in  a  glass-stoppered  bottle  for 
several  months  before  it  is  used. 

Iodin  Caustic. 

Iodin  3  j  (4  Gm.) 

Cresol  fl3  iij  (12  C.c.) 

This  caustic  is  used  in  fistulous  tracts  of  alveolar  abscesses. 

Mustard  ;  Sinapis  Alba,  U.  S.  P.,  B.  P. ;  Sinapis  Nigra,  U.  S.  P., 
B.  P. ;  MouTARDE,  F. ;  Senfsamen,  G. 

Mustard  is  represented  in  the  two  pharmacopeias  by  the  dried 
ripe  seeds  of  the  black  and  white  mustard.  Both  seeds  contain 
glucosids;  sinigrin  is  found  in  the  black  seeds  and  sinalbin  in  the 
white  seed.     When  powdered  mustard  seed  is  mixed  with  water, 


266  PHARMACO-THERAPEUTICS 

decomposition  of  its  glueosid  takes  place,  which  results  in  the 
formation  of  the  volatile  oil  of  mustard.  This  oil  is  intensely  ir- 
ritating to  the  skin,  and  when  left  long  enough  in  contact  there- 
with causes  blistering.  Ground  mustard  seed  is  principally  em- 
ployed in  the  form  of  a  plaster  or  leaf  and  as  a  poultice  to  produce 
external  irritation.  When  the  leaf  is  dipped  in  warm  water  for 
a  minute  and  placed  on  the  body  surface,  the  volatile  oil  is  pro- 
duced by  slow  decomposition  of  the  glueosid.  The  poultice  is  pre- 
pared by  mixing  the  ground  seed  with  warm  water ;  it  is  folded  in 
a  napkin  and  then  placed  on  the  body  surfaces.  Mustard,  in  com- 
bination with  powdered  capsicum,  in  the  form  of  bags,  as  sug- 
gested by  Flagg,  or,  still  better,  as  small  dental  plasters,  are  val- 
uable means  of  producing  counterirritation  over  the  roots  of 
teeth.  These  plasters  should  not  be  adhesive;  they  are  merely 
placed  on  the  moist  gums  over  the  seat  of  irritation,  and  held  in 


Fig.   46. 
Dental  mustard  plasters  in  position. 

position  by  a  pledget  of  cotton  and  the  natural  pressure  of  the 
cheek.  A  specially  prepared  dental  mustard  plaster  known  as 
sinasin  dental  plaster  deserves  to  be  recommended  on  account  of 
its  excellent  efficiency. 

Capsicum;  Capsicum,  U.  S.  P.,  B.  P.;  Cayenne  Pepper;  Red 
Pepper  ;  Chillies  ;  Poivre  de  Cayenne,  F.  ;  Spanischer 
Pfeffer,  G. 

The  dried  ripe  fruit  of  Capsicum  fastigiatum.  Capsicum  con- 
tains some  ill-defined,  nonvolatile  bodies  which  act  as  powerful 
irritants.  It  is  principally  employed  externally  in  the  form  of  a 
liniment  or  plaster,  and  internally  as  a  stomachic. 

Cantharides;  Cantharis,  U.  S.  P.,  B,  P, ;  Spanish  Fly;  Can- 

THARIDES,    F,  ;    SpANISCHE   FlIEGE,    G. 

It  is  the  dried  beetle,  Cantharis  vesicatoria.  The  beetles  con- 
tain cantharidin,  a  derivative  of  benzol,  which  is  a  powerful  vesi- 


IRRITANTS    AND    COUNTER   IRRITANTS  267 

cant.  In  the  form  of  a  cerate,  plaster,  or  collodion,  it  is  largely 
used  as  a  blistering  agent.  In  the  mouth,  the  cantharidal  collodion 
is  occasionally  employed,  but  there  is  rarely  any  need  for  the  use 
of  this  powerful  remedy. 

Ammonia    Water;    Aqua    Ammonite,    U.    S.    P.;    Liquor    Am- 
monia, B.  P.;  Eau  d'Ammoniaque,  F. ;  Salmiakgeist,  G. 

It  is  an  aqueous  solution  of  ammonia  (NH3),  containing  10 
per  cent  by  weight  of  gaseous  ammonia. 

Stronger  Water  of  Ammonia;  Aqua  Ammonice  Fortier,  U.  S. 
P. ;  Liquor  Ammonice  Fortier,  B.  P.  An  aqueous  solution  of  am- 
monia, containing  28  per  cent  (32.5  per  cent,  B.  P.)  by  weight  of 
gaseous  ammonia. 

Ammonia  Liniment;  Linimentum  Ammonice,  U.  S.  P.,  B.  P. 
A  volatile  liniment,  containing  3.5  per  cent  (2.5  per  cent,  B.  P.) 
of  ammonia. 

The  various  ammonia  solutions  are  principally  employed  in  di- 
luted form  as  liniments  in  popular  medicines;  they  act  as  rube- 
facients, and  are  used  in  sprains,  bruises,  etc.  As  skin  irritants 
and  vesicants  they  are  rarely  employed  at  present.  In  the  form 
of  smelling  salts,  ammonia  is  used  by  inhaling  its  gas  as  a  reflex 
stimulant  in  fainting,  etc. 

Alcohol,  per  se,  or  as  a  solvent  of  essential  oils  and  other  vola- 
tile substances — spirit  of  camphor,  chloroform,  juniper,  lavender, 
peppermint,  spearmint,  etc. — is  Avidely  used  as  an  external  irritat- 
ing lotion.  The  alcoholic  solutions  of  volatile  substances  com- 
bined with  anodynes  are  often  applied  to  the  face  as  antineu- 
ralgics. 

Hoff's  Dental  Liniment. 

R     Chloroform. 

Ether.  aa  fl3  ij   (8  C.c.) 

Menthol.  3  j   (4  Gm.) 

Spirit,    camphor.  fl3  j   (4  C.c.) 

Spirit,  rosmarin.  fl3  ij   (8  C.c.) 

Aquse  Ammoniae  fl3  v  (20  C.c.) 

Tinct.  capsic.  flS  j   (30  C.c.) 

M.  f .  liniment. 

Sig. :  For  external  use  only.  With  a  wad  of  cotton  the 
liniment  is  applied  to  the  painful  surfaces  of  the  cheek  in 
neuralgia.    Care  should  be  taken  not  to  get  it  into  the  eyes. 


268  pharmaco-therapeutics 

English  Smelling  Salt. 

Ammonium  carbonate  3  xx  (80  Gm.) 

Ammonium  chlorid  3  v   (20  Gm.) 

Oil  of  lavender  fl3  j   (4  C.c.) 

Oil  of  lemon  fl3  ss  (2  C.c.) 

Oil  of  bergamot  fl3  %   (1  C.c.) 

Alcohol  fl3  j   (4  C.c.) 

Glycerin  fl3  j   (4  C.c.) 

The  salts  are  coarsely  powdered  and  perfumed  with  the 
alcoholic  solution  of  the  oils;  lastly  add  the  glycerin.  Keep 
in  well-stoppered  bottles. 


ANTACIDS. 

Antacids  are  agents  which  neutralize  acids  by  their  alkaline  or 
basic  properties ;  their  action  is  always  of  a  chemic  nature.  In  gen- 
eral medicine,  antacids  are  usually  employed  to  reduce  the  acidity 
of  the  secretions  of  the  stomach  and,  sometimes,  of  the  urine,  and 
to  increase  the  reduced  alkalinity  of  the  blood.  In  dentistry  they 
are  used  to  locally  neutralize  hyperacidity  of  oral  secretions.  Be- 
fore applying  an  antacid  the  acidity  of  the  oral  secretions  should 
be  positively  established.  To  test  the  secretions,  the  mouth  must 
be  rinsed  with  a  warm  physiologic  salt  solution,  and  the  saliva 
is  now  collected  by  letting  it  drip  from  the  open  mouth,  head 
bent  forward,  into  a  suitable  vessel.  To  determine  the  reaction  of 
saliva  in  the  oral  cavity  with  test  papers  (litmus,  etc.)  is  abso- 
lutely unreliable.  The  relationship  of  saliva  to  dental  caries  is  re- 
ferred to  under  Preparations  for  the  Mouth  and  Teeth. 

The  action  of  the  chemicals  used  in  the  mouth  for  the  purpose 
of  neutralizing  the  oral  secretions  is  only  of  a  temporary  char- 
acter. The  insoluble  carbonates  of  calcium  and  magnesium  and 
the  hydrate  of  the  latter  are  preferred  for  such  work.  The  readily 
soluble  sodium  bicarbonate  is  only  of  temporary  assistance.  Caus- 
tic alkalies  must  be  carefully  avoided  in  the  mouth. 

If  antacids  are  indicated,  the  best  time  for  their  application  is 
in  the  evening  before  retiring.  After  the  mouth  is  thoroughly 
rinsed  the  teeth  should  be  evenly  coated  with  the  hydrate  of  mag- 
nesium (milk  of  magnesia),  or  a  thin  mixture  of  precipitated  cal- 
cium carbonate  and- water,  and  left  in  place  over  night.  All  traces 
of  the  coating  should  be  removed  by  thorough  rinsing  the  follow- 
ing morning. 


antacids  269 

Precipitated  Calcium  Carbonate;  Calcii  Carbonas  Precipi- 
TATUS,  U.  S.  P.,  B.  P.;  CaCOg;  Precipitated  Chalk;  Calcium 
Carbonate;  Carbonate  de  Chaux,  F.;  Pracipitirter  kohlen- 

SAURER  KaLK,  G. 

It  is  a  fine  white,  impalpable  powder,  without  odor  and  taste, 
and  permanently  in  the  air.  It  is  nearly  insoluble  in  water  and 
insoluble  in  alcohol.  In  diluted  acetic,  hydrochloric,  or  nitric 
acid  it  is  completely  soluble,  with  effervescence. 

Prepared  Chalk;   Creta  Pr^eparata,  U.   S.  P.,  B.  P.;   CaCOg; 
Whiting;  Craie  Lavee,  F. ;  Schlemmkreide,  G. 

It  is  a  native  calcium  carbonate,  freed  from  most  of  its  im- 
purities by  elutriation.  It  is  a  white  or  grayish  fine  powder  or  in 
the  form  of  conical  drops;  odorless  and  tasteless,  and  permanent 
in  the  air.  Chemically  it  behaves  like  the  precipitated  calcium 
carbonate.  Calcium  carbonate  forms  the  base  of  many  of  the 
solid  and  semi-solid  commercial  tooth  preparations.  Only  the  very 
best  precipitated  calcium  carbonate,  and  not  prepared  chalk, 
should  be  utilized  for  such  purposes  to  prevent  mechanical  abra- 
sion of  the  enamel.     (See  Preparations  for  the  Mouth  and  Teeth.) 

Solution  of  Calcium  Hydroxid;  Liquor  Calcis,  U.  S.  P.,  B.  P.; 
Lime  Water;  Eau  de  Chaux,  F. ;  Kalkwasser,  G. 

It  is  a  saturated  solution  of  slacked  lime  in  water,  containing 
about  0.15  per  cent  of  calcium  hydroxid.  It  is  a  clear,  colorless 
liquid,  without  odor  and  having  an  alkaline,  feebly  caustic  taste. 

Average  Dose. — 4  fluidrams  (16  C.c). 

Magnesium  Carbonate;  Magnesii  Carbonas,  U.  S.  P.;  (MgCog)^ 
Mg(OH)2+5H20;  Magnesh  Carbonii  Levi,  B.  P.;  Mag- 
nesii Carbonas  Ponderosa,  B.  P.;  3(MgC03),Mg(OH)2+ 
4H2O ;  Magnesie  Blanche,  F.  ;  Kohlensaure  Magnesia,  G. 

Magnesia;  Magnesii  Oxidum,  U.  S.  P. ;  Magnesii  Oxidum  Pon- 
derosum,  U.  S.  P. ;  Magnesia  Levis,  B.  P. ;  MgO ;  Heavy  Mag- 
nesium Oxid;  Magnesie  Calcinee,  F. ;  Gehrannte  Magnesia,  G. 
These  magnesium  compounds  form  white  masses  or  amorphous 
powders,  with  an  earthy,  but  not  saline,  taste.  They  are  prac- 
tically insoluble  in  water  and  alcohol,  but  readily  soluble  in  acids, 
with  effervescence. 

Average  Dose. — 30  grains  (2  Gm.). 


270  PHARMACO-THERAPEUTICS 

Milk  of  Magnesia;  Magma  Magnesice,  U.  S.  P. ;  Lait  de  Magnesie, 
F.;  Magnesiamilch,  G.  It  is  a  hydrate  of  magnesia,  and  forms  a 
semigelatinous  liquid,  containing  freshly  precipitated  magnesium 
liydroxid  prepared  by  the  interaction  of  magnesium  sulphate  and 
ammonia  water;  the  precipitate  is  collected  and  washed  with  dis- 
tilled water  until  the  washing  ceases  to  give  a  reaction  for  sul- 
phates. Hydrated  magnesia  mixtures  containing  gum  arable, 
tragacanth,  or  other  gummy  substances  should  not  be  used. 
Sodium  Bicarbonate  ;  Sodii  Bicarbonas,  U.  S.  P.,  B.  P. ;  NaHCOg ; 

Bicarbonate  de  Soude,  F.  ;  Doppeltkohlensaures  Natron,  G.. 

It  is  a  white,  odorless  powder,  having  a  cooling,  mildly  alkaline 
taste.  It  is  soluble  in  about  12  parts  of  water  at  ordinary  tem- 
perature; hot  water  gradually  decomposes  its  solution.  It  is  in- 
soluble in  alcohol.    With  acids  its  solutions  effervesce  strongly. 

Average  Dose. — 15  grains  (1  Gm.). 

BLEACHING  AGENTS. 

Dental  hleacJiing  agents  are  chemicals  used  for  the  purpose  of 
removing  pigmentations  from  tooth  structure.  By  bleaching  we 
understand  the  destruction  or  changing  of  a  color  compound  into 
a  colorless  material ;  it  is  caused  by  the  ehemic  reaction  which 
ensues  between  the  bleaching  agent  and  the  color  compound. 

Discoloration  of  a  tooth  is  usually  the  result  of  the  death  of  its 
pulp,  although  metallic  stains  and  pigmentations  from  medicines 
or  other  materials  used  in  the  tooth  may  also  be  causative  factors. 
Superficial  stains  of  the  enamel  or  dentin,  which  are  removed  by 
simple  mechanical  means,  are  not  classed  as  discolorations. 

Causes  of  Discoloration. 

The  causes  of  discoloration  may  be  due  to  organic  or  inorganic 
substances.  The  organic  pigments  may  arise  from  the  changes 
which  occur  in  a  dead  pulp  or  from  medicinal  substances. 
Whether  the  pulp  dies  from  mechanical,  ehemic  (including  bac- 
terial), or  thermal  causes  has  no  bearing  on  the  formation  of  the 
pigment.  The  inorganic  pigments  are  the  result  of  ehemic 
changes  which  occur  through  the  formation  of  soluble  salts  of  the 
various  metals  used  in  or  about  the  teeth — fillings,  posts,  reten- 
tion appliances,  etc.  The  color  range  of  pigmentation  depends  on 
the  nature  of  the  cause ;  a  dying  pulp  may  produce  all  shades  be- 


BLEACHING    AGENTS  271 

tvveen  a  pinkish  hue,  yellow,  brown,  bluish-gray,  and  black,  while 
metallic  stains  usually  assume  the  color  of  their  respective  salts. 
The  decomposition  of  the  hemoglobin  of  a  dying  pulp  apparently 
forms  certain  sulphur  compounds — iron  sulphid,  etc. — which 
are  held  principally  responsible  for  the  discoloration,  although 
this  supposition  is  as  yet  not  fully  proved.  The  theoretical  con- 
sideration of  these  changes  has  been  interestingly  discussed  by 
Kirk^  and  Buckley,^  and  the  reader  is  referred  to  their  com- 
munications for  further  information.  The  pinkish  pigmentation 
is  the  result  of  a  sudden  effusion  of  blood  into  the  dentinal  tubules ; 
it  has  been  observed  after  the  application  of  arsenic  on  the  ex- 
posed pulp,  in  typhoid  fever,  cholera,  and  other  acute  exanthema, 
and  in  persons  whose  death  is  caused  by  hanging  or  drowning.^ 
If  it  is  due  to  exanthematous  diseases,  without  death  of  the  pulp, 
the  normal  color  of  the  tooth  usually  returns  with  the  termination 
of  the  disease.  Of  the  medicinal  substances,  oil  of  cassia  and 
eugenol,  which  are  freely  used  by  many  practitioners  in  the  treat- 
ment of  putrescent  root  canals,  are  the  chief  organic  coloring 
agents  met  with  in  discolored  teeth.  These  substances  contain 
furfurol,  a  colorless  pyromucic  aldehyd,  which  readily  turns 
brown  on  exposure  to  air  and  light.  (See  Oil  of  Cassia.)  It  pro- 
duces a  light-brown  color  of  the  tooth  substance.  So  far  as  known, 
the  other  essential  oils  which  are  usually  employed  in  the  treat- 
ment of  the  teeth  do  not  contain  pigment  agents.  Arsenical 
pastes  as  purchased  at  dental  depots  are  sometimes  colored  with 
organic  pigments.  The  author  has  seen  a  tooth  turning  bright- 
blue  within  twenty-four  hours  from  the  application  of  an  arseni- 
cal paste  containing  methylene  blue. 

Metallic  stains  in  teeth  vary  materially  in  their  color;  the  lat- 
ter depends  on  the  metal  from  which  the  soluble  salt  is  derived. 
The  gold  stain  may  result  from  the  injudicious  use  of  gold  instru- 
ments in  the  process  of  bleaching,  from  gold  left  in  a  tooth  prior 
to  bleaching,  or  from  gold  coming  in  contact  with  nitrohydro- 
chloric  acid — as  when  the  acid  is  employed  for  the  purpose  of  en- 
larging a  root  canal.  The  stain  produced  is  of  a  pinkish  hue,  and 
is  the  result  of  the  chlorin  action  on  the  gold.  In  course  of  time 
the  pink  color  changes  to  violet  or  purple,  and  finally  becomes 

•Kirk:  American  Text  Book  of  Operative  Dentistry,   1911,  p.   535. 
*  Buckley:  Johnson's  Text  Book  of  Operative  Dentistry,  1915,  p.  367. 
•Bell:  The  Anatomy,  Physiology,  and  Diseases  of  the  Teeth,  1837,  p.    12. 


'272  PHARMACO-THERAPEUTICS 

black.  Iron  stains  are  produced  by  steel  instruments  when  used 
in  connection  with  mineral  acids,  iodin,  or  chlorin;  at  first  they 
assume  a  yellowish  tint,  which  later  turns  brow^n  or  black.  Nickel 
and  copper  stains  arise  from  the  use  of  these  metals  or  their  alloys 
in  or  about  the  teeth — German  silver  (also  known  as  platinoid, 
Victoria  metal,  etc.),  copper  amalgam,  brass,  etc.  The  copper 
stain  is  the  well-known  bluish-black  color  (copper  amalgam  stain) 
which  we  find  so  frequently  in  Europeans  who  have  their  teeth 
filled  with  this  alloy,  and  the  nickel  stain  is  a  grass-green  color, 
which  finally  turns  black.  Silver  stains  are  jet  black;  they  are 
principally  the  result  of  the  too  free  application  of  silver  nitrate 
(and  of  silver  lactate  and  citrate)  in  substance  or  in  solution.  The 
typical  discoloration  of  silver  salts  on  the  teeth  is  known  as  dental 
argyria.  (See  Silver  Nitrate.)  Mercury  stains  are  principally 
caused  by  the  change  of  mercuric  chlorid  into  a  sulphid;  the 
shades  range  from  a  slate-blue  to  a  distinct  black.  (See  Mercuric 
Chlorid.)  Mercuric  chlorid  was  formerly  freely  used  in  the 
treatment  of  teeth;  on  account  of  the  resultant  discoloration  it 
has  been  abandoned  for  such  purposes.  Manganese  stains  result 
from  the  decomposition  of  manganese  salts,  especially  potassium 
permanganate,  which  in  former  years  was  frequently  employed 
as  an  antiseptic  in  the  treatment  of  putrescent  root  canals;  the 
stains  are  of  a  deep-brown  color. 

Superficial  stains  found  on  teeth — the  discolorations  resulting 
from  the  use  of  tobacco,  the  eating  of  various  fruits  (black  cher- 
ries, blueberries,  etc.),  and  the  green  discoloration  on  the  teeth 
of  children  (growth  of  various  molds  and  fungi) — are  readily 
removed  mechanically.  This  also  holds  good  for  the  superficial 
metal  stains  found  on  the  teeth  of  certain  metal  workers,  especial- 
ly brass  polishers,  etc.  The  habitual  chewing  of  the  betol  nut. 
Areca  catechu,  by  the  natives  of  India,  Africa,  and  other  oriental 
countries  produces  a  permanent  reddish  and  often  a  black  stain  on 
their  teeth. 

Preparing  the  Tooth  for  Bleaching. 

Before  starting  the  bleaching  process,  a  careful  diagnosis  should 
be  made  to  possibly  ascertain  the  cause  of  the  pigmentation.  If 
the  latter  can  be  definitely  traced,  it  is  a  simple  matter  to  select 
the  proper  bleaching  agents.  The  close  observation  of  a  few  gen- 
eral details  governing  all  bleaching  processes  is  essential  to  insure 


blp:aching  agents  273 

ultimate  success.  The  tooth  under  consideration,  prior  to  the 
bleaching  process,  must  receive  proper  treatment  as  regards  its 
pathologic  condition.  The  septic  contents  of  the  pulp  chamber 
and  the  canal  have  to  be  removed,  and  any  existing  disturbances 
about  the  pericementum  must  be  promptly  relieved.  The  upper 
two-thirds  of  its  aseptic  canal  are  now  permanently  closed  with 
cement,  and  the  tooth  is  then  ready  for  the  bleaching  process. 
The  rubber  dam  must  always  be  applied  over  the  tooth  under 
treatment,  including,  according  to  circumstances,  an  additional 
tooth  on  either  side.  It  should  be  sufficiently  large  to  completely 
cover  the  mouth  and  nose,  so  as  to  prevent  the  inhalation  of  aris- 
ing gases — chlorin,  etc.  The  dam  is  carefully  tucked  under  the 
free  margin  of  the  gum,  and,  to  prevent  seeping  of  the  bleaching 
agent  under  the  dam,  a  waxed  silk  ligature  is  passed  twice  about 
the  tooth  and  tied  with  a  few  knots,  lingually  and  labially.  As  an 
additional  precaution,  the  ligature  and  the  dam  in  the  immediate 
vicinity  are  painted  with  sandarac  varnish  or  thin  chloro-percha. 
It  is  understood  that  all  carious  tissue,  metallic  fillings,  etc.,  have 
been  removed,  and  that  the  root  canal  up  to  the  cement  filling  is 
sufficiently  enlarged  to  present  a  clear  view  of  the  interior  of  the 
tooth.  A  thorough  swabbing  with  aceton  will  complete  the  pre- 
liminary preparations. 

The  instruments  to  be  used  in  applying  the  bleaching  agents 
should  be  made  of  vulcanite,  bone,  ivory,  or  wood.  All  metallic 
instruments  with  the  exception  of  those  made  of  zinc  or  aluminum, 
should  be  carefully  avoided,  as  they  are  easily  affected  by  the 
chemicals,  especially  chlorin,  which  readily  forms  soluble  metal- 
lic salts,  and  the  latter  may  give  rise  to  permanent  stains  of  the 
tooth  substance. 

Bleaching  Processes. 

Two  methods  are  at  present  in  vogue  for  the  destruction  of 
organic  pigments  in  teeth,  and  both  methods  depend  on  the  pres- 
ence of  oxygen.  The  oxidation  method  depends  on  the  utiliza- 
tion of  free  oxygen  as  liberated  from  oxygen  compounds,  either 
directly  or  indirectly,  and  the  reduction  method  depends  on  the 
abstraction  of  oxygen  from  the  color  compound.  Oxygen,  in  its 
nascent  state,  is  readily  obtained  by  the  decomposition  of  certain 
compounds  which  contain  it,  loosely  bound,  to  a  greater  or  lesser 
extent.     The  principal  compounds  are  sodium  dioxid,  25  per  cent 


274  PHARMACO-THERAPEUTICS 

ethereal  solution  of  hydrogen  dioxid  (pyrozon),  30  per  cent  aque- 
ous solution  of  hydrogen  dioxid  (perhydrol),  barium  dioxid, 
alphozon,  acetozon,  ammonium  chlorid  in  combination  with  the 
official  solution  of  hydrogen  dioxid,  etc.  Indirectly,  oxygen  may 
be  liberated  by  the  action  of  free  chlorin  or  moisture;  in  the  pres- 
ence of  the  latter,  chlorin  readily  unites  with  the  hydrogen  of  the 
hydrogen  oxid  (water)  molecule,  forming  hydrochloric  acid  and 
setting  free  nascent  oxygen.  The  chemicals  usually  employed  for 
such  purposes  are  chlorinated  lime  or  its  solutions — Labarraque's 
solution,  etc.  (see  page  134) — acted  upon  by  a  weak  acid,  as  acetic, 
tartaric,  or  oxalic  acid. 

The  reduction  method  is  based  on  the  liberation  of  oxygen  from 
a  color  compound  by  the  action  of  a  powerful  reducing  agent; 
sulphurous  acid  is  universally  employed  for  practical  purposes. 
''Its  activity  is  due  to  its  affinity  for  oxygen,  and  it  bleaches  by 
seizing  upon  and  combining  with  that  element  of  the  color  mole- 
cule, thus  destroying  its  identity,  and  consequently  its  color." 
(Kirk.) 

The  universal  method  employed  at  present  for  the  bleaching  of 
teeth  consists  in  the  utilization  of  free  oxygen.  (See  Solutions 
Which  Evolve  Nascent  Oxygen.)  Sodium  dioxid,  introduced  by 
Kirk  in  1893,  is  readily  available  for  this  purpose.  It  may  be 
used  in  dry  form  or  as  a  saturated  solution.  The  dry  powder  or 
a  thick  paste,  made  by  mixing  it  with  chloroform,  is  packed  into 
the  tooth  with  suitable  vulcanite  or  ivory  instruments,  a  drop  of 
distilled  water  is  placed  on  the  powder,  and  atomic  oxygen  is  at 
once  set  free  according  to  the  equation : 

Na20,+H20=2NaOH+0. 

Nascent  oxygen  is  a  powerful  oxidizer,  and  readily  attacks  any 
organic  material  with  which  it  comes  in  contact.  If  the  pigmenta- 
tion of  the  teeth  is  derived  from  organic  sources,  the  destruction 
of  the  color  is  soon  manifested  by  the  bleached  appearance  of  the 
tooth.  The  latter  assumes  a  creamy  color  as  a  result  of  the  freshly 
prepared  sodium  hydroxid,  which  penetrates  deeply  into  the 
tubules.  To  remove  this  j-ellowish  tint  and  to  enhance  the  libera- 
tion of  atomic  oxygen,  a  weak  acid,  usually  sulphuric  or  hydro- 
chloric acid  in  5  to  10  per  cent  solution,  is  now  applied.  If  the 
bleaching  is  not  satisfactorily  accomplished  after  the  first  two 
trials,  a  further  attempt  should  be  made  within  the  next  few  days. 


BLEACHING    AGENTS 


275 


After  the  bleaching  the  tooth  should  be  thoroughly  washed  with 
hot  distilled  water,  and  filled  with  gutta-percha  until  the  next 
visit  of  the  patient.  It  is  good  practice  to  bleach  the  discolored 
tooth  a  few  shades  lighter  than  its  mate,  as  a  bleached  tooth  usual- 
ly loses  the  higher  shades  in  a  little  while.  After  the  operation  is 
completed  the  dry  cavity  is  varnished  with  a  colorless  varnish, 
lined  with  a  cement  which  in  color  corresponds  to  the  shade  of 
the  tooth,  and  a  permanent  filling  may  then  be  inserted. 

If  a  saturated  solution  of  sodium  dioxid  (see  page  145)  is  used 
instead  of  the  powder,  the  procedure  is  very  much  the  same.  The 
liquid  is  best  carried  to  the  tooth  on  a  wooden  toothpick  wrapped 
with  asbestos  wool;  the  latter  is  previously  heated  in  a  flame. 
Kirk  states  that  "the  sodium  dioxid  method  removes  more  com- 
pletely than  any  other  the  tubular  contents,  and  the  result  is 
unique  from  the  fact  that  not  alone  is  the  tooth  restored  to  the 


Fig.  47. 
"Eveready"  mouth  lamp. 


normal  color,  but  to  normal  translucency ;  the  opaque  white  ef- 
fect resulting  from  other  methods  is  due  to  the  bleached  organic 
debris  remaining  in  the  tubules,  but  by  the  solvent  action  of  the 
strong  caustic  alkali  this  is  removed." 

The  application  of  concentrated  solutions  of  hydrogen  dioxid 
for  bleaching  purposes  is  much  the  same  as  that  employed  for 
sodium  dioxid  or  its  solutions.  Perhydrol,  being  an  aqueous 
neutral  solution  containing  about  100  per  cent  of  available  oxygen 
by  volume,  is  especially  suitable  for  the  purpose.  The  solution  is 
applied  as  stated  or  a  piece  of  coarse  gauze  is  tied  about  the  tooth 
(under  rubber  dam)  and  the  undiluted  perhydrol  is  dropped  up- 
on it  with  a  medicine  dropper.  A  piece  of  cotton,  saturated  with 
perhydrol  has  been  placed  previously  into  the  root  canal  and 
cavity.  To  facilitate  the  ready  evolution  of  oxygen  the  rays  of 
an  electric  light  are  now  applied  to  the  Avet  gauze.    The  source  of 


276 


PHARMACO-THERAPEUTICS 


light  may  be  obtained  from  any  of  the  dental  illuminators,  the 
Zeiss  bleaching  apparatus,  or  a  small  tungsten  lamp,  fed  by  a 
dry  cell  battery.  A  short  tube  fitted  over  the  lamp  will  focus  the 
light  rays  in  the  desired  direction.     The  object  is  to  concentrate 

the  mixed  light  rays  (i.e.,  light, 
heat,  and  chemic  rays),  upon  the 
gauze  wet  with  perhydrol  so  as  to 
facilitate  the  ready  liberation  of 
nascent  oxygen.  Excellent  results 
are  obtained  by  this  simple  pro- 
cedure. 

The  bleaching  of  teeth  by  cata- 
phoresis  is  only  of  historic  interest 
at  present. 

In  bleaching  teeth  by  the  chlo- 
rin  method,  or  the  Truman  meth- 
od, as  it  is  sometimes  referred  to 
in  honor  of  its  discoverer,  the  pro- 
cedure is  as  follows :  The  general 
preparation  of  the  tooth  is  the 
same  as  outlined  above.  A  high- 
grade  preparation  of  chlorinated 
lime,  obtained  in  an  original  con- 
tainer and  manufactured  by  a  re- 
liable chemical  house,  is  of  prime 
importance  to  obtain  good  results. 
The  necessary  quantity  of  the 
powder  is  mixed  with  distilled 
Avater  to  a  stiff  paste  and  placed 
into  the  tooth.  As  much  moisture 
as  possible  is  removed  with  pellets 
of  cotton,  and  a  weak  acid,  prefer- 
ably diluted  acetic  acid,  is  now 
applied,  and  the  cavity  is  immedi- 
ately sealed  with  temporary  stop- 
ping. The  treatment  is  repeated  in  one  or  two  days,  or  as  often 
as  necessary  until  the  normal  color  of  the  tooth  is  restored. 

Metallic  stains  require  specific  treatment.^     Gold,  iron,  copper, 
and  nickel  stains  are  best  removed  by  the  chlorin  method;  silver 


Fig.  48. 
Zeiss  tooth  bleaching  lamp. 


>Kirk:  American  Text  Book  of  Operative  Dentistry,  1911,  p.   535. 


PREPARATIONS    FOR    THE    MOUTH   AND   TEETH  277 

nitrate  stains  are  removed  by  chlorin,  or  by  first  saturating  the 
tooth  with  tincture  of  iodin  and  then  applying  a  saturated  solu- 
tion of  sodium  hyposulphite.  Mercurial  stains  are  removed  by 
an  ammoniacal  solution  of  dydrogen  dioxid,  followed  by  a  satu- 
rated solution  of  potassium  iodid.  The  stains  of  "manganese  yield 
readily  to  a  concentrated  solution  of  hydrogen  dioxid  (perhydrol) 
saturated  with  oxalic  acid. 

PREPARATIONS  FOR  THE  MOUTH  AND  TEETH. 
(Oral  Hygiene.) 

Oral  hygiene — the  science  of  oral  health,  treats  of  the  preserva- 
tion of  the  normal  equilibrium  of  the  oral  cavity  and  its  contents. 
The  remedies  intended  for  the  maintenance  of  the  health  of  the 
soft  structures  of  the  mouth  and  the  teeth  may  be  conveniently 
divided  into  those  prescribed  for  specific  diseased  conditions  and 
those  employed  as  hygienic  measures  for  daily  use.  Only  those 
employed  for  the  hygienic  purposes  are  claiming  our  interest  at 
present. 

In  the  mouths  of  most  civilized  races,  the  mucous  membrane,  on 
account  of  the  present  perverted  methods  of  preparing  and  sea- 
soning our  foodstuffs,  is  found  more  or  less  always  in  a  state  of 
mild  chronic  inflammation,  while  the  hard  structures  of  the  oral 
cavity,  the  teeth,  are  subjected  to  a  process  of  molecular  destruc- 
tion, known  as  dental  caries.  Dental  caries  is  not  a  disease  in 
the  same  strict  sense  of  the  word  in  which  the  latter  term  is 
usually  applied,  but  is  "a  process  distinctly  allied,  both  in  its 
chemic  and  bacteriologic  aspects,  to  the  general  phenomena  of 
putrefaction."  (Goadby.)  While  certain  preliminary  intrinsic 
causes,  i.  e.,  anomalies  of  position,  outline,  and  structure,  etc., 
may  profoundly  alter  the  predisposition  of  the  tooth  to  carious 
destruction  as  a  whole  or  in  part,  dental  caries  will  always  occur 
if  a  tooth  is  subjected  to  the  influences  of  suitable  environments 
and  it  does  not  matter  whether  the  tooth  forms  an  integral  part 
of  the  anatomy  of  the  individual,  or  whether  it  is  separated  whol- 
ly or  in  part  from  its  original  owner.  The  late  Miller  has 
formulated  an  explanation  of  the  nature  of  the  carious  process, 
which,  at  present,  is  universally  accepted  and  which  defines  this 
phenomenon  as:  a  chemico-parasitic  process  consisting  of  two  def- 
inite states,  i.  e.,  the  decalcification  of  the  tissues  and  the  dissoln- 


278  PHARMACO-THERAPEUTICS 

tion  of  the  remaining  organic  matrix.  In  caries  of  the  enamel,  the 
latter  phenomenon  is  not  observed  on  account  of  the  minute  quan- 
tities of  organic  matter  contained  therein.  The  accumulation  of 
carbohydrate  food  debris  on  and  about  the  teeth  is  held  directly 
responsible  as  being  the  incipient  factor  in  the  production  of  the 
decalcifying  agents.  The  direct  or  indirect  splitting  up  of  these 
carbohydrates  by  fission  fungi  into  acids,  i.  e.,  principally  lactic 
acid,  furnishes  the  attacking  agent  which  decalcifies  the  enamel. 
The  further  changes  occurring  in  this  process  of  tooth  disor- 
ganization do  not  interest  us  at  this  moment. 

The  hygienic  care  of  the  mouth  intends  primarily  to  keep  the 
mucous  membrane  and  the  teeth  in  a  state  of  healthy  equilibrium 
by  overcoming  the  above  enumerated  morbific  processes.  Nature 
has  instituted  protective  measures  of  her  own  to  accomplish  the 
desired  end.  The  normal  mouth  is  fairly  well  protected  against 
the  continual  onslaughts  of  the  omnipresent  bacteria  through  an 
unusually  rich  blood  supply  of  the  oral  tissues,  a  high  resistance 
of  their  epithelial  lining,  and  a  free  flow  of  saliva.  The  vigorous 
use  of  the  organs  of  mastication  during  the  chewing  of  properly 
selected  food  will  bring  about  an  active  circulation  and  stimula- 
tion of  the  parts  involved  and,  as  a  sequence,  a  rich  flow  of  saliva 
required  for  the  washing  away  of  food  debris  and  for  the  prelim- 
inary digestion  of  carbohydrate  food  is  alwajs  insured. 

Human  saliva  represents  the  mixed  secretions  from  the  three 
pairs  of  salivary  glands  and  the  minute  mucous  glands  distributed 
over  the  oral  cavity.  Saliva  may  be  defined  as  being  a  weak  solu- 
tion of  alkalis,  as  present  in  the  body  juices,  more  or  less  sat- 
urated with  carbon  dioxid.  It  contains,  furthermore,  several  or- 
ganic substances,  among  which  mucin  and  the  several  ferments 
which  accelerate  the  changes  of  starches  into  maltose,  i.  e.,  the 
hydrolj-sis  of  polysaccharids  into  soluble  disaccharids.  The  fer- 
ments of  human  saliva  are  principally  represented  by  the  carbo- 
hydrate-splitting type,  i.  e.,  amylase  (ptj^alin)  and  maltase. 
although  oxydase  and  catalase  are  always  present  in  more  or  less 
variable  quantities.  The  physiologic  function  of  mucin  consists 
in  mechanically  assisting  the  food  bolus  in  its  easy  passage  into 
the  stomach  and  to  protect  the  oral  tissues  against  irritating  sub- 
stances. 

The  biolncrip  Inws  troverning  the  secretion  of  saliva  are  directly 
responsible  for  its  composition,  its  quantity,  and  its  influence  on 


PREPARATIONS    FOR    THE    MOUTH    AND   TEETH  279 

the  digestion  and,  incidentally,  on  dental  caries.  Only  the  most 
fundamental  facts  concerning  these  biologic  aspects  can  be  touched 
upon  at  this  moment.  The  secretion  of  saliva  depends  upon  nerv- 
ous impulses.  The  quantity  of  saliva  secreted,  i.  e.,  the  rapidity 
of  its  flow  depends  upon  the  physical  nature  of  the  stimulant 
(foodstuffs).  Psychic  stimulation  is  of  less  importance  in  this 
connection.  Incidentally,  the  composition  of  saliva  depends  very 
largely  upon  the  rapidity  of  flow,  i.  e.,  its  organic  and  inorganic 
contents  are  primarily  the  sequences  as  produced  by  the  nature 
of  the  stimulant.  The  stimulant  induces  these  changes,  not  mere- 
ly in  the  oral  mucous  membranes,  but  also  in  those  of  the  stomach. 
The  latter  seems  to  respond  through  the  formation  of  hormones. 
Apparently,  as  has  been  shown  experimentally  by  Pawlow  and  his 
pupils,  saliva  is  a  glandular  secretion  capable  of  adaptation.  How- 
ever, the  fundamental  basis  of  the  secretion  of  saliva  rests  with 
the  process  of  mastication,  i.  e.,  the  degree  and  the  manner  of 
mastication  accelerates  or  diminishes  very  materially  the  nature 
of  the  stimulant.  The  much  discussed  alkalinity  of  saliva  depends 
directly  on  its  ash  contents,  i.  e.,  the  more  ash,  the  higher  the 
alkalinity.  With  an  increase  of  the  rapidity  of  flow  an  increase 
of  alkalinity  is  always  observed.  Alkalinity  of  saliva  as  deter- 
mined by  titration  is  always  a  "one  man's"  finding  and  not  to 
be  relied  upon.  To  correctly  determine  the  reaction  of  a  fluid 
which,  as  saliva,  hovers  so  closely  near  the  neutral  point  the  elec- 
trometric  measurement  of  the  H-ion  concentration  is  the  only  per- 
missible scientific  method.  The  writer  has  successfully  employed 
for  such  work  the  gas-chain  apparatus  as  modified  by  Michaelis. 
The  reaction  of  normal  saliva,  i.  e.,  saliva  collected  during  periods 
of  physiologic  rest  of  the  salivary  glands  is  so  very  weakly  alka- 
line that  its  influence  as  a  so-called  neutralizing  medium  of 
"acidity"  of  the  mouth  is  practically  nil.  As  the  quality  of 
saliva  when  collected  during  active  digestion  is  always  an  ex- 
pression of  the  nature  of  the  last  meal  taken,  saliva  intended  for 
analysis  should  be  collected  during  resting  hours  of  the  digestive 
apparatus.  The  normal  healthy  grown  individual  produces  dur- 
ing waking  hours  approximately  1  C.c.  of  saliva  per  minute.  Dur- 
ing mastication,  as  stated  aTaove,  depending  upon  the  nature  of 
the  foodstuff,  this  amount  may  be  greatly  increased. 

PickerilP  has  made  the  assertion  that  the  principal  function 

'PJckerill:  Prevention  of  Dental  Caries  and  Oral  Sepsis,  r,ondon,  1914. 


280  PHARMACO-THERAPEUTICS 

of  saliva  consists  in  the  hydrolysis  of  starches  and  thus  prevents 
dental  caries.  The  writer  has  not  been  able  experimentally  in  the 
human  mouth  to  show  any  relationship  between  the  amylase 
(ptyalin)  content  of  saliva  and  dental  caries.  Amylase  may  be 
readily  paralyzed  or  accelerated  by  many  chemic  agents.  Pure 
amylase  is  inactive  as  a  ferment;  certain  inorganic  ions,  especial- 
ly the  chlorin  ion  (sodium  chorid)  accelerates  its  activity  ten  times 
or  more.  Normal  quantities  or  even  relatively  large  quantities 
of  amylase  may  be,  and,  occasionally,  are  present  in  the  most  ram- 
pant forms  of  caries.  In  certain  animals,  as  for  instance  in  the 
domestic  dog,  very  little  or  no  amylase  is  present  in  the  saliva  al- 
though the  dog  is  relatively  immune  to  dental  caries. 

The  much  discussed  bactericidal  action  of  the  saliva,  which  is 
claimed  to  be  due  to  the  presence  of  small  and  ver^'  variable 
quantities  of  potassium  sulphoeanid,  has  been  disproved  by  the 
classic  researches  of  Miller,^  Bruylant,^  Gies  and  Kahn,^  and 
Kantorowicz.'*  Recently,  an  attempt  "was  made  to  revive  the  influ- 
ence of  sulphocyanids  in  its  relation  to  the  causation  of  dental 
caries.  Dental  caries  does  not  depend  on  the  living  body  as  a 
whole,  and,  as  a  consequence,  the  presence  or  absence  of  this 
chemical  in  metabolic  processes  as  related  to  dental  caries  plays 
no  part.  In  the  normal  mouth  pathogenic  micro-organisms  are 
usually  less  virulent,  and  they  are  the  subordinates  of  the 
saprophydic  types.  Fliigge'  has  shown  that  the  pathogenic  bac- 
teria will  become  extremely  active  if  the  individual  is  afflicted 
with  a  slight  local  disturbance — as  a  simple  catarrh  of  the  throat. 
Claermont  has  expressed  similar  views,  and  after  a  careful  study 
of  the  fluids  of  the  mouth  he  asserts  that  one  is  not  justified  in 
stating  that  saliva  possesses  any  definite  bactericidal  action.  It 
seems,  however,  that  the  parotid  saliva  of  man  and  of  some  animals 
(especially  the  goat)  exercises  an  inhibitory  function  on  certain 
micro-organisms — the  staphylococci  and  the  streptococci. 

Very  recently  an  hypothesis  relative  to  definite  defensive  or 
protective  organisms  possessed  or  produced  by  nature  to  com- 
bat the  ravages  of  dental  caries  has  been  promulgated.  This  con- 
ception is  based  on  the  ingenious  experimental  researches  of  Ab- 


>  Miller:  Deutsche  Monatsschrift  fiir  Zahnheilkunde,   1903. 
»BruyIant:  Jahresbericht  der  Tierchemie,  Vol.  XVIII. 
•Kahn:  Biochemical  Studies  of  Sulphocyanates,  Eaton,  1912. 
*  Kantorowicz:   Deutsche   Monatsschrift   fiir  Zahnheilkunde,    1913. 
•Flugge:  Berichte  des  Chemischen  Institutes,  Breslau,  1900. 


PREPARATIONS    FOR   THE    MOUTH    AND   TEETH  281 

derhalden,  who  holds  the  view  that  diseased  processes  are  primari- 
ly regulated  by  defensive  ferments.  This  conception  of  the  causa- 
tion of  dental  caries  is  based  on  a  misinterpretation  of  the  Abder- 
halden  theory.  As  we  have  stated  above  and  wish  to  state  again, 
dental  caries  is  not  a  disease;  it  is  a  process  of  molecular  disin- 
tegration which  may  occur  in  a  tooth,  whether  this  tooth  forms  a 
part  of  the  anatomy  as  a  whole,  or  whether  it  is  detached  there- 
from. The  writer,  while  working  on  this  very  question  in  Ab- 
derhalden's  former  laboratory  at  the  University  of  Berlin  (1913- 
14),  convinced  himself  of  the  fact  that  defensive  ferments  in  the 
sense  of  Abderhalden 's  protective  theory,  play  no  part  in  the 
process  of  dental  caries. 

The  fermentative  changes  of  the  various  types  of  saccharids 
into  soluble  sugars,  the  mechanical  washing  away  of  accumu- 
lated food  debris,  and  the  ability  of  biologically  inhibiting  the 
virulence  of  pathogenic  bacteria  are  the  important  functions  per- 
formed by  a  freely  flowing  saliva  and  thereby  maintain  the 
physiologic  equilibrium  of  the  oral  cavity. 

Immunity  to  dental  decay,  in  the  writer's  opinion,  depends — 
ccBteris  paribus — first,  on  a  tooth  free  from  imperfections  of  cal- 
cification and,  second,  on  a  freely  flowing  saliva. 

Immunity  as  referred  to  tooth  structure  is,  in  the  strict  sense 
of  the  word,  a  misnomer  as  it  is  not  bound  up  with  vital  phenom- 
ena. In  a  biologic  sense,  immunity  indicates  a  state  in  which  the 
"living"  body  resists  disease.  In  a  pulpless  tooth,  it  goes  without 
saying  that  we  are  dealing  with  dead  structure  as  far  as  the 
enamel  is  concerned  and  it  is  this  latter  tissue  only  that  concerns 
us  in  the  elucidation  of  the  question:  Why  do  teeth  decay?  In  a 
tooth  with  a  vital  pulp  the  writer  holds  the  view  that  enamel  is 
capable  of  carrying  on  metabolic  processes  to  a  limited  degree. 
He  is  able  to  substantiate  this  claim  by  certain  pharmacologic 
reactions  which,  however,  he  can  not  discuss  at  this  moment.  The 
surface  of  so-called  living  enamel  he  regards  practically  as  dead 
structure  which  offers  no  vital  resistance  to  the  physico-chemic 
process  of  decay.  The  omnipresent  surface  colloids  and  the  col- 
loidal fluids  present  in  the  enamel  in  teeth  with  living  pulps 
modify  the  process  of  decay.  All  teeth  which  are  imperfectly  cal- 
cified on  account  of  their  lowered  resistance  will  sooner  or  later 
decay  until  relative  immunity  is  established  in  accordance  with 
the  imperative  law  of  "survival  of  the  fittest."    If,  however,  the 


282  PHARMACO-THERAPEUTICS 

flow  of  saliva  is  impaired  or  completely  checked,  all  teeth  will  be 
destroyed  by  caries  unless  some  other  means  for  the  removal  of 
food  debris  is  established.  The  rapidity  of  the  destructive  pro- 
cesses is  proportionately  dependent  upon  the  severity  of  the  im- 
pairment. Normally,  the  flow  of  saliva  is  regulated  by  the  in- 
tensity of  the  stimulus  as  evinced  during  mastication.  The  stim- 
ulation by  acids  is  of  a  temporary  nature  only,  and  of  less  im- 
portance. Therefore,  vigorous  mastication  or,  as  it  is  called  by  a 
recently  popularized  term :  fletcherizing,  of  correctly  selected 
foodstuffs  forms  the  basis  for  the  natural  prevention  of  dental 
decay.  To  substantiate  our  contention  relative  to  the  position 
which  saliva  occupies  in  the  prevention  of  caries,  we  may  cite  a 
few  examples.  In  xerostomia,  i.  e.,  inhibition  of  secretion  of 
saliva,  the  teeth  will  begin  to  crumble  away  with  the  onset  of  the 
dry  mouth.  During  other  temporary  pathologic  disturbances  of 
glandular  activity,  i.  e.,  continuous  fevers  (typhoid),  menopause, 
pregnancy,  diabetes,  etc.,  clinically  a  marked  increase  of  dental 
caries  is  always  observed.  The  change  of  environments  of  food 
supply,  i.  e.,  if  the  natural  struggle  for  existence  in  gathering 
food  is  supplanted  by  artificially  furnished  food  of  a  prepared 
type,  a  marked  preponderance  of  dental  caries,  even  in  hitherto 
immune  herbivorous  animals  is  always  observed  as,  for  instance, 
in  monkeys  in  captivity.  The  skulls  of  wuld  horses  verj'-  rarely 
show  carious  defects;  the  domesticated  horse  is  in  frequent  need 
of  the  veterinary  dentist.  Subjecting  wild  tribes  of  the  human 
race  to  the  influences  of  civilization  and,  as  a  sequence,  changed 
food  supplies,  will  always  be  followed  by  a  most  marked  increase 
in  dental  caries.  Immigrants  from  countries  where  hard-baked 
black  bread  forms  a  large  part  of  their  staple  diet,  when  coming 
to  the  United  States  are  frequently  subjected  to  intense  ravages 
of  dental  decay.  For  instance,  newly  arrived  Scandinavians,  ac- 
customed to  chewing  "knackebrod"  forget  to  masticate  our  soft 
wheat  bread,  and,  as  they  are  often  forgetful  of  the  blessings  of 
the  tooth  brush,  rampant  decay  is  frequently  manifest  within  a 
few  months  after  landing.  Dental  caries  is  comparatively  rarely 
observed  in  the  teeth  of  habitual  tobacco  chewers.  Miller  and 
others  have  demonstrated  that  tobacco  juice  possesses  no  anti- 
septic action.  Its  prophylactic  effect,  as  far  as  the  teeth  are  con- 
cerned, rests  with  the  pharmacologic  action  of  tobacco,  i.  e..  its  al- 
kaloid nicotin  is  a  powerful  salivary  stimulant. 


PREPARATIONS   FOR   THE    MOUTH    AND   TEETH  283 

In  a  recent  communication  PickerilP  tentatively  admits  the  im- 
portance of  the  quantity  of  salivary  secretion.  He  states:  "I 
would  even  suggest  that  caries  of  the  teeth  may  be  regarded  as  a 
symptom  of  failure  of  the  nervous  mechanism  controlling  salivary 
secretions  to  functionate  normally."  In  the  writer's  opinion  the 
qiiantity  of  the  secreted  saliva  is  the  sole  factor  which  governs 
environmental  phenomena  concerning  tooth  decay. 

The  quantity  and,  to  a  less  extent,  the  quality  of  saliva,  on  ac- 
count of  our  present  methods  of  preparing  and  selecting  food- 
stuffs and  the  consequent  insufficient  mastication,  are  frequently 
inadequate  to  bring  about  a  proper  physiologic  cleansing  of  the 
oral  cavity.  To  assist  -nature,  suitable  mechanical  and  chemic 
means  may  be  employed  to  overcome  this  deficiency.  The  mechani- 
cal cleansing  of  the  mouth  and  teeth  by  means  of  the  brush, 
powder,  paste,  toothpick,  floss  silk,  etc.,  constitutes  the  absolute 
fundamental  principle  of  artificial  oral  hygiene.  Food  remnants 
and  slimy  adhesions  between  and  upon  the  teeth,  together  with  a 
large  number  of  the  adherent  bacteria,  are  principally  removed  by 
mechanical  cleansing.  The  mechanical  cleansing  of  the  oral  cav- 
ity by  these  enumerated  means  may,  however,  be  materially  as- 
sisted by  the  judicious  use  of  suitable  mild  astringent  and  indif- 
ferent antiseptic  solutions.  Powders,  pastes,  and  washes  contain, 
ing  soluble  drugs  or  drugs  in  solution  are  employed  for  the 
avowed  purposes  of  assisting  nature  in  accomplishing  the  desired 
means  to  an  end,  i.  e.,  they  must  favor  the  recovery  of  an  inflamed 
mucous  membrane  and  they  must  mechanically  remove  accumu- 
lated food  debris. 

A  good  oral  preparation  should  possess  the  following  properties : 

(1)  It  must  be  absolutel}^  indifferent  in  regard  to: 

(a)  the  mucous  membrane — non-caustic; 

(b)  the    teeth — non-decalcifying     (mechanical    or    chem- 
ical) ; 

(c)  the  organism  as  a  whole — non-poisonous. 

(2)  It  must  not  interfere  with  the  normal  physiologic  cleansing 
of  the  oral  cavity,  i.  e. : 

fa)     it  must  not  inhibit  the  secretion  of  saliva; 

(b)  it  must  not  perceptibly  alter  the  reaction  of  saliva; 

(c)  it  must  not  destroy  the  ferments  of  saliva. 

(^)     It  must  possess  sufficient  cleansing  action,  combined  with: 


>  Pickerill:   Dental  Cosmos,   1913,  p.   1081. 


284  PHARMACO-THERAPEUTICS 

(4)     Good  taste  and  odor. 

These  various  enumerated  properties  are  naturally  rarely  found 
in  combination  in  a  single  oral  preparation  and  yet  each  one  is 
of  the  utmost  importance. 

Hygienic  measures  as  applied  to  the  oral  cavity  are  practiced 
in  proportion  to  the  pleasant  sensation  which  they  call  forth, 
hence,  a  mouth  preparation  which  has  a  disgusting  taste  is  inef- 
fective because  it  will  not  be  employed  for  any  length  of  time  by 
the  laity.  The  great  mass  of  the  public  will  never  be  induced  to 
practice  oral  hygiene  that  involves  ill-tasting  preparations.  As 
stated  above,  mouth  preparations  must  be  absolutely  free  from 
danger  as  far  as  the  mucous  membrane,  the  teeth,  and  the  organ- 
ism as  a  whole  is  concerned.  Hence  Roese's  dictum  should  be 
indelibly  fixed  in  the  mind  of  every  dental  and  medical  practition- 
er :  The  importance  of  oral  antisepsis  is  not  so  great  that  we  are 
justified  in  assuming  the  slightest  risk.  This  statement  cannot  be 
emphasized  too  strongly  in  view  of  the  fact  that  numberless  mouth 
washes  and  tooth  preparations  of  questionable  character  are  con- 
tinuously forced  on  the  market.  Unless  the  correct  composition 
of  a  ready-made  mouth  or  tooth  preparation  is  known,  it  should 
not  be  recommended. 

The  majority  of  the  so-called  dental  preparations  which  are 
employed  by  the  laity  for  daily  use  belong  to  a  group  of  medicinal 
compounds  generically  known  as  proprietary  preparations.  As 
these  compounds  are  not  used  for  the  avowed  purpose  of  curing 
a  specific  disease  but  rather  as  hygienic  measures  no  objection  can 
be  raised  from  an  ethical  point  of  view  provided  that  they  are 
prepared  from  approved  formulas  and  that  they  conform  to  the 
claims  as  outlined  above. 

A  few  of  the  more  widely  advertised  preparations  which  are  ap- 
parently universally  recommended  by  the  profession,  deserve 
special  notice.  Bad  taste  and  general  unfitness  for  the  purpose 
in  view  are  the  lesser  evils  of  most  of  these  preparations;  some 
are  distinctly  dangerous  to  the  oral  tissues  when  employed  for 
daily  use.  The  conception  that  mouth  washes,  tooth  powders,  and 
pastes  which,  in  general,  are  non-poisonous  and  neutral  in  reac- 
tion are  indifferent  to  the  oral  tissues  is  erroneous:  Many  of 
these  highly  extolled  compounds  sail  under  dubious  flags.  For 
instance,  an  alkaline  thymolated  glycerin  solution  is  claimed  to 
possess  extraordinary  qualities  as  an  oral    antiseptic,    while,    in 


PREPARATIONS   FOR   THE    MOUTH   AND   TEETH  285 

reality,  it  is  about  equally  as  effective  as  a  physiologic  salt  solu- 
tion but  with  a  less  pleasant  taste.  A  50  per  cent  potassium 
chlorate  tooth  paste  at  one  time  furnished  "nature's  antiseptic — 
free-oxygen  which  whitens  the  teeth"  and  while  at  present  it  cures 
"acid  mouth,"  no  trace  of  free  oxygen  was  ever  obtained  from 
the  use  of  this  paste.  The  distinctive  danger  of  potassium  chlorate 
to  the  general  health  is,  of  course,  not  mentioned.  Again,  a  men- 
tholated salol  solution  is  much  lauded  as  "the  most  persistent  oral 
antiseptic."  This  compound  is  rather  prone  to  produce  persist- 
ent eczematous  eruptions  about  the  corners  of  the  mouth.  Very 
recently  a  so-called  "hydrozon"  tooth  paste  has  been  introduced 
by  a  German  manufacturer  of  pharmaceutic  preparations.  It 
is  stated  that  this  paste  produces  nascent  oxygen  when  it  is 
brought  in  contact  with  the  fluids  of  the  mouth.  According  to  the 
patent  claims  this  paste  is  composed  of  an  ordinary  starch  paste 
holding  hydrogen  dioxid  solution  in  suspension.  Small  quantities 
of  plaster  of  Paris  are  added  to  this  mixture  to  bind  the  water  of 
the  hydrogen  dioxid  solution  in  the  form  of  water  of  crystalliza- 
tion. The  presence  of  starch  is  readily  revealed  by  the  iodin  test, 
while,  as  may  be  expected,  the  acid  potassium  chromate  test  does 
not  show  a  trace  of  hydrogen  dioxid  in  a  sample  purchased  in  the 
open  market.  Starch — an  easily  fermentable  carbohydrate — 
added  to  tooth  paste  means  to  whip  the  Devil  with  Beelzebub. 
The  hydrozon  tooth  paste  is  another  sample  of  how  readily  the 
profession  may  be  hoodwinked  by  the  ludicrous  statements  of  so- 
called  reliable  pharmaceutic  manufacturing  concerns.  The  latest 
additions  to  oral  specialties  is  a  tooth  paste  containing  hexamethy- 
lenamin  and  one  which  contains  isoform  (paraiodanisol).  Isoform 
is  an  almost  odorless  substitute  for  iodoform,  while  hexamethylen- 
amin  is  supposed  to  be  decomposed  in  the  mouth  by  the  action  of 
the  alkaline  saliva  into  ammonia  and  formaldehyd.  Salicylic  acid 
and  its  component,  salol,  were  at  one  time,  and  are  still  to  some 
extent,  used  in  mouth  washes.  Chemically,  salol  is  phenyl 
salicylate ;  it  is  split  up  by  the  secretions  of  the  mouth  and  the  in- 
testines into  salicylic  acid  and  phenol.  Salicylic  acid  is  strongly 
keratolytic  in  its  acton,  and  decalcifies  tooth  structure. 
The  recent  craze  for  adding  formaldehyd  to  things  in  general 
which  sail  under  the  elucidative  appellation  of  oral  antiseptics 
has  done  much  harm;  its  addition  to  mouth  washes  in  appreci- 
able quantities  is  distinctly  dangerous.     All  alkalies,  with  the  ex- 


286  PHARMACOTHERAPEUTICS 

ception  of  the  carbonates  of  calcium  and  magnesium  should  be 
used  very  sparingly  in  the  mouth,  while  all  mineral  acids,  with 
the  exception  of  boric  acid,  must  be  positively  forbidden  in  mouth 
and  tooth  preparations.  Most  of  the  widely  advertised  tooth 
powders,  pastes,  and  certain  mouth  washes  contain  too  high  per- 
centages of  soap.  Soap,  on  account  of  its  alkalinity,  invariably 
kills  the  important  salivary  ferments.  The  list  of  ill-constructed 
mouth  preparations  may  be  extended  ad  libitum.  In  spite  of  the 
absurd  claims  made  by  the  manufacturers,  it  seems  incompre- 
hensible that  numerous  practitioners  recommend  such  compounds 
to  their  patients.  The  best  service  that  a  conscientious  practi- 
tioner can  render  to  his  clientele  is  to  absolutely  prohibit  the  use 
of  a  mouth  preparation  of  whose  innocuousness  he  is  not  fully 
convinced. 

The  search  for  so-called  tartar  solvents — substances  which  pre- 
vent or  dissolve  calcareous  deposits  about  the  teeth — as  an  addi- 
tion to  tooth  preparations  has  occupied  the  minds  of  the  dental 
hygienists  for  some  time  past.  The  chemic  nature  of  the  oral 
calculus  indicates  that  its  disintegration  may  be  accomplished  logi- 
cally in  two  ways:  first,  by  dissolving  in  an  acid  or  an  acid  salt 
and  second,  by  disintegration  with  an  alkali  which  removes  its 
organic  matrix  and  thereby  renders  the  remaining  honey-combed 
inorganic  base  an  easy  prey  to  mechanical  abrasives.  Human 
oral  calculus  contains  approximately  25  per  cent  of  organic  sub- 
stances and  water.  For  self-evident  reasons,  acids  and  acid  salts 
can  not  be  employed  for  such  purposes  in  the  oral  cavity.  On  the 
other  hand,  mild  alkalis,  as  the  salines  for  instance,  prevent  the 
ready  formation  of  calculus,  and  they  help  to  remove  fresh  de- 
posits when  brought  in  intimate  contact  therewith.  Just  how 
much  of  this  destruction  or  removal  shoiild  be  attributed  to  the 
mechanical  scrubbing  by  the  brush,  and  how  much  to  the  solvent 
action  by  the  ingredients  of  the  tooth  powder  or  paste  is  very 
difficult  to  determine.  Nevertheless,  sodium  bicarbonate,  the  salts 
of  certain  mineral  springs,  especially  those  of  Carlsbad,  Preblau, 
etc.,  and  similar  artificial  compounds,  are  used  in  concentrated 
form  for  such  purposes,  and  apparently  with  some  success.  Arti- 
ficial Carlsbad  salt  may  be  incorporated  into  a  powder  or  paste 
with  calcium  carbonate  and  other  abrasives;  its  only  drawback  is 
its  somewhat  disagreeable  salty  taste.      Tooth    pastes    containing 


PREPARATIONS   FOR   THE    MOUTH    AND   TEETH  287 

about  25  per  cent  of  artificial  Carlsbad  salt  may  be  obtained  in 
the  market. 

Innumerable  experiments  have  been  made  to  determine  the 
so-called  antiseptic  strength  of  oral  preparations.  As  a  standard, 
the  Rideal- Walker  phenol  coefficient  or  some  other  laboratory 
standard  is  usually  employed  as  a  means  of  arriving  at  some 
tangible  conclusions.  If  these  experiments  are  carried  out  in 
test  tubes  with  cultures  of  isolated  organisms,  comparative  deduc- 
tions drawn  from  such  tests  are  wholly  unwarranted  as  they  do 
not  portray  actual  conditions  existing  in  the  oral  cavity  because 
the  very  premises  upon  which  these  experiments  are  based  are  er- 
roneously chosen.  On  the  other  hand,  if  these  preparations  are 
tested  directly  in  the  mouths  of  normal  individuals,  it  is  invariably 
found  that  in  average  only  50  per  cent  of  the  oral  bacterial  flora 
is  inhibited.  Authorities  agree  that  it  is  impossible  to  render  the 
oral  cavity  sterile,  even  for  a  short  period  only,  with  any  of  the 
so-far-known  antiseptic  solutions  (pastes,  powders,  etc.,  must  en- 
ter into  solution  if  any  antiseptic  effect  is  to  be  expected)  in  the 
strength  in  which  these  solutions  can  be  employed  with  safety. 
The  dilution  of  these  preparations  and  the  short  time  allowed 
for  their  action  in  the  cavity  as  actually  employed  by  the  user 
necessarily  minimizes  their  antiseptic  effect  to  such  an  extent  as 
to  practically  render  the  solutions  inert. 

Recently,  Gies  has  advocated  diluted  vinegar  and  Pickerill  a 
solution  of  acid  potassium  tartrate  as  being  most  efficacious  mouth 
washes.  Both  recommendations  are  based  on  observations  made 
in  the  laboratory;  their  correctness  is  not  substantiated  by  clini- 
cal evidence.  The  recommendation  of  an  acid  mouth  wash  of  the 
above  type  is  based  on  wrong  premises  because,  first,  the  laity 
will  not  be  induced  to  employ  an  ill-tasting  mouth  wash  for  any 
length  of  time,  and  second,  the  pharmacologic  principle  evolved 
in  the  selection  of  such  solutions  is  erroneously  applied.  When 
an  acid  mouth  wash  in  the  form  of  vinegar  or  acid  potassium 
tartrate  is  taken  in  the  mouth,  a  temporary  copious  flow  of  alka- 
line saliva,  rich  in  mucin,  is  produced.  This  alkaline  saliva 
serves  as  a  diluent  and  neutralizer  of  the  acid  and  the  colloidal 
mucin  acts  as  a  protector  of  the  insulted  mucous  membrane  and 
the  teeth — nature's  method  of  getting  rid  of  the  irritant.  In  ac- 
cordance with  Heidenhain's  law  forcible  stimulation  of  salivary 
glands  is  followed  by  impairment  of  their  function.    Incidentally, 


288  PHARMACO-THERAPEUTICS 

the  acidity  of  these  solutions  kills  the  important  salivary  ferments. 

It  has  been  repeatedly  shown  that  a  physiologic  salt  solution 
(approximately  one  dram  of  sodium  ehlorid  to  a  pint  of  boiled 
water)  and  heated  to  body  temperature  reduces  the  oral  flora  by 
50  per  cent  and,  incidentally,  it  is  absolutely  safe.  On  the  other 
hand  clinical  evidence  seems  to  point  to  the  beneficial  effects  which 
are  obtained  by  the  use  of  such  mild  alkaline  astringents  as  well- 
diluted  lime  water.  E.  Kells,  Jr.,  Kirk,  and  many  other  observers 
have  repeatedly  called  attention  to  the  remarkably  good  results  ob- 
tained by  its  continuous  use.  Its  therapeutic  effect  depends  on 
its  solvent  power  of  the  mucin  deposits  on  and  about  the  teeth 
which  mechanically  retain  food  debris  and  bacteria  and  on  the 
formation  of  insoluble  soaps  with  fatty  acids  and  lipoid  substances. 
Incidentally,  the  freshly  precipitated  calcium  carbonate  may  pos- 
sibly exert  some  mechanical  protective  influence  on  the  teeth  them- 
selves. When  employed  in  proper  dilutions,  its  mild  astringent 
effect  favors  the  recovery  of  inflamed  mucous  surfaces  which,  to  a 
mild  degree,  are  almost  universally  present  in  the  mouths  of  most 
persons.  A  tablespoonful  (one-half  ounce)  of  lime  water  added 
to  a  tumblerful  (eight  ounces)  of  physiologic  salt  solution  makes  a 
most  serviceable  mixture  which  may  be  used  as  a  mouth  wash  with 
impunity.  Incidentally,  this  solution  corresponds  more  closely 
to  an  artificial  saliva — nature's  protector  of  the  teeth  and  the 
mucous  membrane — than  any  other  mouth  wash  found  in  the 
market. 

The  following  table  shows  the  relative  value  of  oral  antiseptics 
by  counted  colonies  before  and  after  their  use: 

NAME  OF  PREPARATION*  BEFORE        AFTER      PER  CENT 

Preparation — Tooth  powder    15477  9363  40 

Tooth  powder    12553  6000  50 

Mouth  wash   18732  9164  50 

Tooth  paste   12138  6293  50 

Mouth  wash  22644  11009  50 

Tooth  paste    9975  4969  50 

Tooth  paste   9341  7644  20 

Physiologic  salt  solution  0.85% 11537  7452  40 

Precipitated  chalk 13083  6799  50 

The  writer  has  made  innumerable  tests  with  the  various  dental 
preparations  as  found  in  the  market  and  with  experimental  mix- 

*As  we  have  to  allow  for  possible  errors  of  at  least  10  per  cent,  the  preparations 
are  to  be  counted  as  being  equal  in  their  antiseptic  strength. 


PREPARATIONS    FOR    THE    MOUTH    AND   TEETH  289 

tures  by  plating  out  specific  quantities  used  within  specific  times 
in  the  oral  cavity  and  counting  the  number  of  colonies  before  the 
after  these  tests.  These  experiments  merely  verify  what  has  been 
stated  above,  namely: 

1.  Sterilization  of  the  oral  cavit}'  with  any  of  the  commercial 
dental  preparations  or  any  antiseptic  in  the  strength  in  which 
it  can  be  employed  with  safety,  can  not  be  accomplished. 

2.  The  cleansing  of  the  oral  cavity  with  an  antiseptic  solution 
alone  or  combined  with  the  mechanical  effects  of  the  tooth  brush, 
powder,  or  paste,  reduces  the  number  of  oral  bacteria  approxi- 
mately about  50  per  cent.  The  claims  made  for  the  antiseptic 
strength  of  certain  commercial  preparations  are,  by  actual  tests, 
wholly  unwarranted. 

3.  A  physiologic  salt  solution  of  body  temperature  in  con- 
junction with  the  tooth  brush  and  precipitated  calcium  carbonate 
in  the  form  of  a  powder  or  a  paste  (providing  these  preparations 
are  in  conformity  with  the  claims  as  outlined  above)  are  the  saf- 
est and  most  effective  of  all  so  far  known  artificial  oral  hygienic 
measures. 

Preparations  intended  for  the  mouth  and  the  teeth  exercise 
their  beneficial  influence  on  the  soft  and  hard  tissues  of  the  oral 
cavity  primarily,  by  their  mechanical  cleansing  power  and,  second- 
ly, by  inhibiting  to  a  limited  degree  the  activity  of  the  extremely 
rich  saprophytic  flora  which  is  always  present.  The  increase  of 
bacteria  in  the  oral  cavity  is  enormous,  as  the  conditions  which 
favorably  influence  their  growth  are  ideal  in  this  locality.  Ac- 
cording to  Miller  a  single  cell  may  produce  in  twenty-four  hours 
16,000,000  offspring,  while  Novy  has  estimated  that  the  amount 
of  organic  matter  present  in  30,000,000,000  bacteria  equals  about 
%oo  grain  (0.00016  gm.).  The  mere  preservation  of  the  teeth 
and  their  adnexa  is  not  the  principal  function  of  those  agents 
which  are  employed  as  specific  antiseptic  medications;  many  other 
organs  which  are  directly  or  indirectly  connected  with  the  oral 
cavity  proper  are  frequently  subjected  to  serious  pathologic  altera- 
tions, brought  about  by  microbal  disturbances.  Oral  sepsis,  by 
Avay  of  continuity,  may  involve  the  tonsils,  the  pharynx,  the 
glands  of  the  jaws  and  the  mouth,  the  stomach,  etc.  According 
to  Hunter^  septic  gastritis  and  toxic  neuritis,  and  their  many 
sequela3,    are    the    principal    disturbances    of   a    general    nature 


'Hunter:  Oral  Sepsis,  1901. 


290  PHARMACO-THERAPEUTICS 

brought  about  by  oral  sepsis.  The  local  manifestations  of  oral 
sepsis  vary  greatly;  they  are  of  an  inflammatory  and  suppurative 
nature,  and  may  involve  the  mouth,  jaws,  and  the  adjacent  parts. 
The  mixed  infection  of  dental  caries,  as  well  as  the  many  types  of 
streptococci  and  staphylococci,  are  principally  held  responsible 
by  Hunter  as  the  causative  factors  of  oral  sepsis. 

l*reparations  whi^h  are  intended  to  exercise  definite  functions 
on  the  teeth  and  gums,  the  oral  mucous  membrane,  the  tongue, 
the  salivary  glands,  and  the  tonsils,  and  to  some  extent  on  the 
breath,  are  known  as  oralia.  This  term  has,  however,  never  been 
universally  recognized;  the  physical  nature  of  the  preparation 
has  created  specific  names  for  definite  classes — solid  or  semi-solid 
tooth  preparations  are  known  as  dentifrices,  liquid  tooth  prepara- 
tions are  spoken  of  as  collutoria,  while  liquids  intended  for  the 
pharyngeal  regions  are  referred  to  as  gargles.  Oral  remedies  are 
employed  for  the  purpose  of  preserving  and  restoring  the  normal 
equilibrium  of  the  oral  tissues,  and  consequently  no  specific 
pharmacologic  action  is  represented  by  each  class  of  these  prepara- 
tions— they  represent  merely  a  combination  of  medicinal  agents 
indicated  for  a  clinical  entity.  According  to  their  therapeutic 
indications,  the  drugs  used  in  the  mouth  are  grouped  under 
abrasives,  antacids,  antiseptics,  astringents,  stimulants,  and  cor- 
rectives. 

The  preparations  used  for  the  mouth  and  teeth  are  convenient- 
ly divided  into  mouth  washes,  tooth  powders,  tooth  pastes,  and 
tooth  soaps.  ]\touth  pastils,  cachous,  and  chewing  gums  are  also 
used  by  the  laity ;  they  are  intended  to  flavor  the  breath,  and  pos- 
sess no  medicinal  value. 

Drugs  Used  in  Preparations  for  the  Mouth  and  Teeth. 

In  constructing  a  formula  for  a  mouth  or  tooth  preparation  the 
following  substances  must  be  avoided : 

1.  Strong  precipitants  of  albumen  (concentrated  alcohol,  min- 
eral acids,  with  the  exception  of  boric  acid,  metallic  salts,  phenol, 
and  salicylic  acid  and  most  of  their  derivatives,  etc.). 

2.  Caustics  (potassium  and  sodium  hydroxid  and  many  of 
the  potassium  salts). 

3.  Strong  astringents  (formaldehyd  solution,  etc.). 

4.  Gritty  substances  (pumice  stone,  charcoal,  crude  chalk,  et:.). 


PREPARATIONS   FOR   THE    MOUTH    AND   TEETH  291 

5.  Fermentable  substances  (sugars,  starches,  vegetable  pow- 
ders) . 

6.  Staining  substances  (organic  and  inorganic  dyestuffs,  chin- 
osol,  iron  salts,  manganese  salts,  etc.). 

The  following  is  a  list  of  drugs  which  may  be  employed  in  mouth 
and  tooth  preparations,  and  their  relative  highest  percentages  in 
100  parts  of  the  finished  product. 

Abrasives. 

Cuttlefish  bone 3  to       5  per  cent. 

Soap    2  to       3  per  cent. 

Cinchona  bark   5  per  cent. 

Orris  root 10  per  cent. 

Calamus  root   10  per  cent. 

Calcium  carbonate,  precipitated,  up  to  100  per  cent. 

Antacids. 

Sodium  bicarbonate   5  per  cent. 

Magnesium  carbonate    10  per  cent. 

Magnesium  oxid 10  per  cent. 

Calcium  carbonate,  precipitated,  up  to  100  per  cent. 

Antiseptics. 

Mercuric  bichlorid 0.05  to  0.1  per  cent. 

Benzoic  acid 1  per  cent. 

Sodium  fluorid 1  to  3  per  cent 

Hydronaphtol    1  to  5  per  cent. 

Resorcinol    1  to  5  per  cent. 

Salol     3  to  5  per  cent. 

Phenol    3  to  5  per  cent. 

Potassium    chlorate 1  to  5  per  cent. 

Salicylic   acid 3  to  5  per  cent. 

Magnesium  dioxid 5  to  10  per  cent. 

Sodium  perborate 5  to  10  per  cent. 

Strontium  dioxid 5  to  10  per  cent. 

Boric  acid 10  to  20  per  cent. 

Sodium   borate 10  to  20  per  cent. 

Hydrogen  dioxid  solution 10  to  20  per  eent. 

Astringents. 

Zinc    chlorid 0.05  to  0.1  per  cent. 

Tannic  acid 1  to      2  per  cent. 

Benzoin    5  per  cent. 

Catechu 5  per  cent. 

Kino   5  per  cent. 

Myrrh  5  per  cent. 

Rhatanv    root 2  to    10  per  cent. 


292 


PIIARMACO-THERAPEUTICS 


Stimulants. 

Oil  of  rose 0.1   to  0.5  per  cent. 

Oil  of  ylang-ylang 0.1   to  0.5  per  cent. 

Menthol    0.5  per  cent. 

ThjTnol  0.5  per  cent. 

Eucalyptol   1  per  cent. 

Oil  of  geranium 0.5  to  1  per  cent. 

Oil  of  cinnamon 1  per  cent. 

Oil  of  peppermint 1  per  cent. 

Oil  of  cloves 1  to  2  per  cent. 

Oil  of  eucalyptus 1  to  2  per  cent. 

Oil  of  mountain  pine 1  to  3  per  cent. 

Camphor 1  to  3  per  cent. 

Oil   of  wintergrecii 1  to  5  per  cent. 

Methyl  salicylate 1  to  5  per  cent. 

Alcohol 10  to  100  per  cent. 

Correctives. 

Saccharin 0.0003  per  cent. 

Cumarin   0.5  to  1  per  cent. 

"Vanillin    0.5  to  1  per  cent. 

Glycerin    5  to  10  per  cent. 

Action  of  Antiseptics  in  the  Mouth. 

(W.   D.    MILLER.) 


Drugs. 


Acid  benzoic 

Acid  boric 

Acid  salicylic   

Eugenol   

Hydronaphtol   

lodin  trichlorid   

Lysol    

Mercuric  chlorid,  corrosive 

Oil  of  cinnamon    

Oil  of  cloves    

Oil  of  eucalyptus    

Oil  of  mountain  pine 

Oil  of  peppermint 

Oil  of  wintergreen    

Phenol    

Potassium  chlorate   

Potassium  permanganate  . 

Saccharin     

Solution  aluminum  acetate 
Solution  hvdrogen  dioxid. 
Thvmol    . .' 


Diluti 

on  in  which 

Time  in  which  the 

they  car 

1  be  employed 

mouth  become* 

in  the  mouth. 

sterilized. 

100 

1^    niiniilc 

:      50 

above  11  minutes 

300 

%  to  1  minute 

750 

above  10  minutes 

1,500 

al)0ve  15  minutes 

2,000 

above  I'^A  minutes 

200 

above  5  minutes 

2,500 

1/4  to  %  minute 

400 

above  8  minutes 

550 

above  11  minutes 

625 

above  8  minutes 

360 

above  19  minutes 

600 

above  11  minutes 

350 

above  12  minutes 

100 

above  5  minutes 

40 
4,000 

above  15  minutes 

400 

•*4  rninute 

20 

above  5  minutes 

2: 

100 

nbove  6  minutes 

1: 

2,000 

above  5%  minutes 

PREPARATIONS    FOR    THE    MOUTH    AND    TEETH 


293 


Mouth  Washes. 

A  mouth  wash  is  usually  prescribed  as  a  gargle,  to  ba  used  in 
conjunction  with  the  tooth  brush.  The  components  of  the  wash 
should  be  so  adjusted  that  one  teaspoonful  mixed  with  half  a 
tumblerful  of  warm  water  (approximately  1  to  30)  furnish  the 
correct  proportions  of  its  active  ingredients  intended  for  daily  use. 
The  gargling  motion  is  produced  by  forcing  air  from  the  lungs 
through  the  fluid  held  posteriorly  in  the  mouth.  Powerful  exer- 
cise of  the  muscles  of  the  pharynx,  the  cheeks,  and  the  lips  are 


mm 


Fig.  49. 
lilectric  heater  and  spray  outfit. 


lualei-ial  adjuncts  in  forcing  the  fluid  back  and  forth  through 
llie  teeth.  About  one-half  to  one  minute's  gargling  is  the  average 
time  required  for  each  mouthful,  corresponding  approximately  to 
1/^  to  1  fluidounce  (15  to  30  C.c.)  of  liquid.  Correct  gargling  is 
quite  a  difficult  procedure;  it  can  not  be  well  accomplished  by  chil- 
dren and  those  afflicted  with  pharyngeal  distui-bances.  Through 
incorrect  gargling  a  quantity  of  the  fluid  is  usually  swallowed,  or 
it  merely  turns  about  in  the  anterior  part  of  the  mouth.     If  the 


294  PHARMACO-THERAPEUTICS 

fluids  contain  alcoholic  or  volatile  solutions,  more  or  less  of  it  is 
always  absorbed. 

A  convenient  way  of  spraying  the  oral  cavity  with  a  fluid  anti- 
septic is  readily  accomplished  by  using  an  atomizer.  This  method 
of  applying  an  antiseptic  is  especially  of  service  before  and  after 
the  removal  of  tartar  and  other  operations  about  the  mouth,  in 
children,  and  in  those  who  can  not  gargle.  The  atomizer  bulb 
may  be  worked  by  hand  or  foot  power,  or,  still  better,  by  com- 
pressed air.  An  electric  heater  and  spray  outfit  designed  for 
dental  purposes  is  now  obtainable  from  the  depots;  in  a  compact 
form  it  comprises  two  adjustable  spray  tubes  and  a  hollow  needle 
for  the  purpose  of  conveniently  carrying  the  fluid  to  all  parts  of 
the  mouth,  a  tooth,  pyorrhea  pockets,  the  antrum,  etc.  The  fluid 
in  the  spray  bottles  is  kept  at  body  temperature  by  a  lighted  elec- 
tric bulb.  The  importance  of  this  latter  item  is  often  overlooked : 
an  antiseptic  solution  heated  to  body  temperature  will  not  only 
avoid  unnecessary  thermal  shock,  but  will  increase  its  own  action 
materially. 

Tooth  and  mouth  washes  are  usually  dispensed  in  flint  glass 
bottles,  stoppered  with  corks  or  metallic  sprinkler  tops.  If  the 
latter  are  used,  the  contents  of  the  bottle  must  not  corrode  the 
metallic  tops. 

Antiseptic  Mouth  "Wash.* 

Boric   acid    25  parts. 

Benzoic  acid    1  part. 

Thymol    3  parts. 

Oil  of  wintergreen 5  parts. 

Eucalyptol    5  parts. 

Menthol     6  parts. 

Glycerin     100  parts. 

Alcohol    250  parts. 

Water enough  to  make  1,000  parts. 

Dissolve  the  oil  of  wintergreen,  eucalyptol,  thymol,  menthol, 
and  benzoic  acid  in  the  alcohol;  mix  the  glycerin  and  the  water 
and  add  the  boric  acid;  mix  the  two  solutions,  add  20  parts  of 
talc,  shake  occasionally,  and  let  stand  for  four  days.  Filter 
through  paper. 

The  solution  reacts  slightly  acid.  The  quantities  of  benzoic  and 
boric  acid  as  represented  in  the  formula  have  absolutely  no  ill  ef- 

'  N.  B. — Parts  as  used  in  these  prescriptions  mean  quantities  by  weight. 


PREPARATIONS   FOR   THE    MOUTH    AND    TEETH  295 

feet  on  the  tooth  structure  or  on  the  mucous  membrane.  If  an 
alkaline  mouth  wash  is  desired,  the  following  solution  will  answer 
the  purpose. 

Alkaline  Mouth  Wash.^ 

Sodium    bicarbonate    30  parts. 

Sodium  benzoate    20  parts. 

Sodium  borate    50  parts. 

Menthol    6  parts. 

Thymol   3  parts. 

Eucalyptol   3  parts. 

Alcohol    100  parts. 

Glycerin    200  parts. 

Water enough  to  make  1,000  parts. 

Anatherin  Dentifrice.^ 

Red  sandal  wood   20  parts. 

Guaiac  wood   10  parts. 

Myrrh    25  parts. 

Cloves   15  parts. 

Cinnamon   . ; 5  parts. 

Oil  of  cinnamon 1  part. 

Oil  of  cloves 1  part. 

Alcohol   1,500  parts. 

"Water 750  parts. 

Eau  de  Botot.^ 

Star  anise  seed 25  parts. 

Cinnamon,  Ceylon 25  parts. 

Cloves   25  parts. 

Cochineal    10  parts. 

Potassium  bitartrate   5  parts. 

Tannic   acid    5  parts. 

Balsam  of  Peru 5  parts. 

Oil  of  peppermint 10  parts. 

Alcohol,  diluted 1,000  parts. 

Pruyn*s  Mouth  Wash.^ 

Boric  acid   18  parts. 

Oil   of   cassia 6  parts. 

Phenol    6  parts. 

Chloroform    6  parts. 

Alcohol  150  parts. 

Oil   of    peppermint 1  part. 

Glycerin enough   to   make  400  parts. 

*  N.  B. — Parts  as  used  in  these  prescriptions  mean  quantities  by  weight 


296  pharmaco-therapeutics 

Miller's  Mouth  Washes.* 
1. 

Thymol     1  part. 

Benzoic  acid   12  parts. 

Tincture    of   eucalyptus 60  parts. 

Alcohol     400  parts. 

Oil    of    peppermint 3  parts. 

Z. 

Benzoic    acid    60  parts. 

Tincture  of  rhatany 250  parts. 

Oil  of  peppermint 15  parts. 

Alcohol enough  to  make  2,000  parts. 

Resorcinol  Mouth  Wash.* 

Boric  acid   5  parts. 

Sodium  borate    18  parts. 

Resorcinol    18  parts. 

Eau   de   cologne 200  parts. 

Water enough  to  make  500  parts. 

Pickerill's  Acid  Mouth  Wash.* 

Potassium  bitartrate   2  parts. 

Tartaric   acid    2  parts. 

Oil  of  lemon 3  parts. 

Saccharin    i^  part. 

Water enough  to  make  480  parts. 

Romer's  Mouth  Wash.* 

Thymol    0.5  part. 

Menthol    0.5  part. 

Saccharin    0.5  part. 

Alcohol   70  parts. 

Hydrogen   dioxid   solution 120  parts. 

Saccharin  Mouth  Wash.* 

Saccharin    0.5  part. 

Sodium  borate 4  parts. 

Alcohol   50  parts. 

Water   50  parts. 

Tincture  of  cochineal 14  part. 

Oil  of  peppermint 1  part. 

*  N.   B. — Parts  as  used  in   these  prescriptions  mean   quantities  by  weight. 


preparations  for  the  mouth  and  teeth  297 

Astringent  Hydrogen  Dioxid  Wash.^ 

Kesorcinol    50  parts. 

Zinc   chlorid    0.3  part. 

Menthol    5  parts. 

Thymol   2  parts. 

Eucalyptol    14  part. 

Camphor 14  part. 

Oil  of  wintergreen i^  part. 

Solution    hydrogen    dioxid 200  parts. 

Alcohol 250  parts. 

Water    enough  to  make  1,000  parts. 

Zederbaum's  Chinosol  Mouth  Wash.^ 

Chinosol    14  part. 

Glycerin    30  parts. 

Cassia  water    30  parts. 

Water   240  parts. 

Colors  for  Mouth  Washes. 

Bright  red   tincture  of  cochineal. 

Reddish-brown  tincture  of  cudbear. 

Brown  caramel  solution. 

Golden  yellow   tincture  of  saffron. 

Green chlorophyl  solution. 


Tooth  Powders. 

Tooth  powders,  pastes  and  soaps  are  principally  employed  for 
the  purpose  of  mechanically  cleansing  the  accessible  surfaces  of 
the  teeth.  Their  antiseptic  effect  on  oral  bacteria  is  of  question- 
able value,  as  they  remain  hardly  long  enough  in  the  mouth  to 
enter  into  a  complete  solution.  Tooth  powders  or  pastes  should 
not  contain  gritty  or  fermentable  substances  or  corrosive  chemi- 
cals, which  act  deleteriously  on  tooth  structure.  The  wasting  away 
of  tooth  tissues,  usually  referred  to  as  erosion  or  abrasion,  is  large- 
ly the  result  of  the  continuous  use  of  poAvders,  pastes,  etc.,  which 
contain  more  or  less  abrasive  substances,  as  the  late  Miller^  has 
shown.  He  deducts  the  following  conclusions  from  his  experi- 
mental work: 


»  N.  B. — Parts  as  used  in  these  prescriptions  mean  quantities  by  weight. 
'Miller:    Experiments  and    Observations   on   the   Wasting   of   Tooth    Tissue,    Variously 
Designated  as  Erosion,  Abrasion,  Chemic  Abrasion,  Denudation,  etc..  Dental  Cosmos,  1907. 


298  PHARMACO-THERAPEUTICS 

"With  some  of  the  much  extolled  preparations  on  the  market  it  is  quite 
easy,  by  applying  the  brush  as  nearly  as  possible  in  the  same  manner  as  it 
would  be  used  in  the  mouth,  to  cut  the  tooth  half  through,  exposing  the 
pulp,  inside  of  two  hours.  ...  In  fact,  I  was  not  satisfied  with  examin- 
ing the  preparations  microscopically,  but  where  there  -nas  any  doubt  I  tested 
them  by  brushing  the  teeth  with  them.  Of  the  dentifrices  examined  a  con- 
siderable number  cut  teeth  rapidly;  while  nearly  all  the  others  cut  the  teeth 
to  some  extent,  the  one  that  cut  the  least  of  all  that  I  have  examined  was 
one  which  consists  almost  wholly  of  sodium  bicarbonate.  I  was  surprised  to 
find  that  even  precipitated  chalk  wore  the  dentin  away  rapidly;  but  this,  one 
can  understand  in  view  of  the  fact  that  the  substance  consists  of  a  mass  of 
fine  crystals,  which,  although  they  are  very  small,  are  still  sharp,  and  suffi- 
ciently hard  to  abrade  the  dentin.  Prepared  chalk  acts  on  the  teeth  with  a 
rapidity  depending  on  the  amount  of  impurities  which  it  contains.  We  shall 
find  on  washing  out  prepared  chalk  that,  among  different  preparations,  some 
contain  considerable  quantities  of  remains  of  shells  and  other  gritty  sub- 
stances, which  make  them  unfit  for  use  as  tooth  powder.  Other  preparations 
which  are  comparatively  free  from  these  impurities  act  more  slowly  upon  the 
dentin. ' ' 

The  materials  which  are  principally  employed  in  the  manufac- 
ture of  commercial  tooth  powders,  pastes,  and  soaps  are  prepared 
chalk,  precipitated  calcium  carbonate,  magnesium  carbonate,  soap, 
pumice  stone,  cuttlefish  bone,  orris  root,  and  many  other  sub- 
stances— as  vegetable  powders  of  various  kinds,  borax,  boric  acid, 
potassium  bitartrate,  alum,  charcoal,  etc.  Some  of  these  sub- 
stances possess  a  pronounced  abrasive  character,  while  others  are 
polishing  agents  consisting  of  various  degrees  of  grit.  The  vege- 
table powders  are  principally  used  as  adjuvants  and  diluents; 
their  use  in  tooth  powders  is  not  to  be  encouraged,  as  they  may 
lodge  between  the  teeth,  and  the  starch,  which  is  present  in  most 
of  these  powders  in  variable  quantities,  may  be  the  cause  of  acid 
fermentation. 

An  acquaintance  with  the  physical  nature  of  the  ingredients 
entering  into  the  makeup  of  tooth  preparations  in  regard  to  their 
abrasive  qualities  is  essential  for  the  dental  practitioner.  A  micro- 
scopic examination  of  the  more  important  powdered  substances,  to- 
gether with  a  comparative  knowledge  of  their  physical  and 
chemic  composition,  furnishes  excellent  information  regarding 
their  usefulness  as  components  of  dentifrices. 

Prepared  chalk,  drop  chalk,  whiting,  creta  prceparata,  a  white 
amorphous  powder,  is  crude  calcium  carbonate,  purified  by  me- 
chanical means.     Prepared  chalk  is  not  precipitated  chalk   (cal- 


PREPARATIONS   FOR   THE    MOUTH    AND   TEETH 


299 


cium  carbonate,  precipitated).  Prepared  chalk  contains  in  addi- 
tion silica,  alumina,  and  other  impurities,  and  consists  principally 
of  the  microscopic  shells  of  many  forms  of  infusoria.  The  minute 
particles  of  prepared  chalk  are  sufficiently  hard  and  sharp  to  re- 
move tooth  substance  when  used  in  a  dentifrice,  and  should  there- 
fore never  be  employed  for  such  purposes. 


Fig.  so. 

Magnified  specimens  of  Tooth  powder  substances.  Magnification,  350\-.  A,  powdered 
pumice  stone;  B,  powdered  cuttlefish  bone;  C,  powdered  charcoal;  D,  powdered  potassium 
bitartrate. 

Precipitated  chalk,  precipitated  calcium  carbonate,  calcii  car- 
honas  prcecipitatus,  is  a  fine  white,  amorphous  powder,  prepared 
by  chemic  means.  Depending  upon  the  process  of  manufacture, 
various  grades  of  fineness,  weight,  and  color  are  obtained.  For 
the  purpose  of  preparing  tooth  powders,  pastes,  etc.,  only  the  very 
finest  bolted  precipitated  calcium  carbonate  is  permissible. 


300 


PHARMACO-THERAPEUTICS 


Prepared  oyster  shells,  concha  prceparata,  testa  prmparata,  are 
prepared  from  the  boiled,  cleansed,  and  powdered  shells  of  the 
oyster,  Ostrea  edulis.  They  consist  principally  of  an  impure  cal- 
cium carbonate,  with  variable  quantities  of  calcium  phosphate,  and 
small  amounts  of  iodin,  bromin,  organic  matter,  etc.  The  powder 
usually  emits  a  peculiar  sea  odor.     The  abrasive  power  of  pow- 


Fig.  51. 


Magnified  specimens  of  tooth  powder  substances.  Magnification,  350x.  A,  powdered 
magnesium  carbonate;  T?,  powdered  prepared  chalk;  C,  precipitated  calcium  carbonate, 
heavy;  D,  precipitated  calcium  carbonate,  washed. 

dered  oyster  shells  is  about  equal  to  that  of  prepared  chalk,  and 
the  same  objection  is  raised  to  their  use  as  a  tooth  powder  base. 

Pumice  stone,  lapis  pumicis,  is  a  light,  porous  stone  of  volcanic 
origin,  consisting  chiefly  of  silica,  with  potash  and  soda.  As  may 
be  expected  from  its  composition,  it  is  a  powerful  abrasive,  and  it 


PREPARATIONS   FOR   THE    MOUTH    AND   TEETH 


301 


should  never  enter  into  a  tooth  preparation  intended  for  daily  use. 
Even  its  temporary  use  in  conjunction  with  precipitated  chalk 
acts  deleteriously  on  tooth  structure. 

Magnesium  carbonate,  magnesii  carhonas.  Two  forms  of  mag- 
nesium carbonate  are  known — the  light  and  the  heavy.  The  light 
preparation  is  usually  employed  for  tooth  powder  purposes.  It 
has  no  abrasive  or  polishing  action  on  tooth  structure.     As  it  is 


Fig.  52. 

Magnified  specimens  of  lootli  powder  substances.  Magnification,  3S0x.  A,  precipitated 
calcium  carbonate  (precipitated  by  heat);  B,  precipitated  calcium  carbonate  (Schenngs); 
C,  powdered  orris  root;  D,  Ijorax  tooth  powder. 

a  voluminous  powder,  it  is  principally  used  to  give  bulk  to  tooth 
powders.  Burnt  magnesia,  Magnesii  oxiduni,  Magnesia  usta,  is 
prepared  from  magnesium  carbonate  by  calcination.  It  possesses 
no  advantage  over  magnesium  carbonate,  and  is  rarely  used  at  pres- 
ent as  a  component  of  dentifrices. 


302  PHARMACO-THERAPEUTICS 

Cuttlefish  hone,  ossa  sepios,  is  a  calcareous  substance  found  under 
the  skin  of  the  back  of  the  cuttlefish,  Sepia  officinalis.  It  is  com- 
posed of  calcium  carbonate,  calcium  phosphate,  gluten,  and  other 
substances  which  are  readily  recognized  by  their  peculiar  putrid 
odor.  The  external  hard  skin  and  the  internal  soft  deposits  of  the 
cuttlefish  bone  are  ground  together,  forming  a  powder,  which  is 
used  as  an  abrasive. 

Charcoal,  carbo  ligni,  carbo  tilice,  is  a  very  fine  black  powder 
prepared  from  soft  wood  (linden  wood).  It  is  odorless  and  taste- 
less, and,  when  freshly  prepared,  readily  absorbs  offensive  odors. 
Even  the  finest  charcoal  powder  presents  a  mass  of  sharp  crystal- 
line cylinders  under  the  microscope,  which  possess  marked  abra- 
sive power.  When  used  as  a  component  in  a  tooth  powder,  the 
sharp  particles  imbed  themselves  in  due  time  in  the  gum  tissue, 
producing  a  distinct  bluish  line  near  the  margin.  The  gum  tissue 
becomes  tattooed  by  the  charcoal,  and  nothing  can  remove  this 
pigmentation  but  a  surgical  operation.  Charcoal  should  not  be 
used  in  a  tooth  preparation;  it  is  often  found  in  the  so-called 
Chinese  and  Japanese  tooth  powders. 

Soaps. — Soaps  must  be  used  very  sparingly  in  oral  cosmetics.  A 
good  tooth  preparation  should  not  contain  more  than  2  to  3  per 
cent  of  the  best  quality  of  castile  soap.  Many  of  the  commercial 
preparations,  especially  tooth  pastes  and,  naturally,  tooth  soaps, 
contain  by  far  too  large  quantities  of  soap.  Soaps  are  either  potas- 
sium or  sodium  oleates  (see  Antiseptics — the  Alkalies),  they  are 
strong  astringents  and,  in  concentrated  solutions,  caustics.  If  used 
in  concentrated  form,  they  have  a  tendency  of  lowering  the  re- 
sistance of  the  mucous  linings  of  the  oral  cavity  by  maceration. 
Even  the  so-called  neutral  soaps  (which  do  not  exist,  however) 
when  employed  in  concentration  above  3  per  cent,  invariably  de- 
stroy the  important  salivary  ferments.  Soaps  are  employed  in 
tooth  preparations  for  the  purpose  of  emulsifying  food  debris,  pre- 
cipitated mucin,  freshly  deposited  tartar,  etc.,  adhering  to  the 
tooth  surfaces.  The  churning  up  of  the  abrasive,  usually  pre- 
cipitated chalk,  present  as  a  base  in  most  of  the  tooth  powders 
and  pastes,  plus  the  foam  produced  by  the  brush  and  water, 
mechanically  remove  these  adhesions.  If  a  strong  emulsifying 
agent  is  desired  in  combination  with  a  tooth  preparation,  the  of- 
ficial tincture  of  quillaya  should  be  employed.  When  used  in  con- 
junction with  warm  water,  soap  acts  as  a  mild  antiseptic. 


PREPARATIONS    FOR   THE    MOUTH    AND    TEETH 


303 


Powdered  vegetable  drugs — as  the  roots  of  calamus,  rhatany, 
licorice,  and  orris,  cinchona  bark,  sandal  wood,  myrrh,  benzoin, 
etc. — have  no  place  in  tooth  powders.  As  stated  above,  they  are 
added  to  give  flavor  to  the  powder  or  to  increase  its  bulk.  The 
odor  and  taste  of  these  vegetable  substances  is  readily  substituted 
Iiy  their  respective  essential  oils  or  alcoholic  extracts.     The  short 


Fig.  53. 


Magnified   specimens  of  tooth  powder  substances.      Magnification,   350x.     A,   B,   C,   D, 
le  of  the  more  widely  used  commercial  tooth  powders,  of  which  D  is  an  especially  fine 


some 
preparation. 


time  in  which  a  tooth  powder  remains  in  the  mouth  is  not  long 
enough  to  allow  the  active  constituents  of  these  substances  to  en- 
ter into  solution.  Their  abrasive  action  is  of  no  value,  but,  as  these 
vegetable  powders  may  be  forced  between  the  teeth  and  remain 
there  for  some  time,  their  starch  constituent  may  give  rise  to  acid 
fermentation. 


304  PHARMACO-THERAPEUTICS 

Tooth  powders  are  preferably  dispensed  in  glass  bottles  or  tin 
fans  with  suitable  sprinkler  tops.^ 

Bodies  for  Colored  Tooth  Powders.' 

BED. 

Carmin  No.  40 20  parts. 

Ammonia   water    50  parts. 

Water   20  parts. 

Alcohol    30  parts. 

Calcium    carbonate,    precipitated 1,000  parts. 

Dissolve  the  carmin  in  the  ammonia  water,  add  the  water  and 
alcohol,  and  mix  thoroughly  with  the  calcium  carbonate.  Spread 
on  paper  and  dry  at  room  temperature;  rub  through  a  No.  50 
brass  wire  sieve. 

PINK. 

Prepare  same  as  red  body,  using  only  one-half  of  the  carmin, 
10  parts. 

VI0LET.2 

Alkanet   extract    2 1/^  parts. 

Ether    100  parts. 

Calcium  carbonate,  precipitated 1,000  parts. 

Prepare  same  as  red  body. 

Camphor  or  English  Tooth  Powder.' 

Calcium  carbonate,  precipitated 750  parts. 

Magnesium  carbonate   120  parts. 

Sugar  of  milk 130  parts. 

Camphor 20  parts. 

Ether    30  parts. 

Dissolve  the  camphor  in  the  ether,  mix  with  the  calcium  car- 
bonate, dry  in  the  air,  and  mix  with  the  other  ingredients. 

Fitzgerald's  Tooth  Powder.' 

Calcium    carbonate,    precipitated 360  parts. 

Magnesium  carbonate   300  parts. 

Castile   soap    150  parts. 

Salol 60  parts. 

Boric  acid   30  parts. 

Thymol  2  parts. 

Saccharin   i^  part. 

Oil  of  peppermint 5  parts. 


'For   further    infonnation    sec    Prinz:    Dental    Formulary,    3d    Edition,    Smith    and    Son 
Co.,  Pittsburgh,  Pa. 

*  N.  B. — Parts  as  used  in  these  prescriptions  mean  quantities  by  weight. 


preparations  for  the  mouth  and  teeth  305 

Harlan's  Tooth  Powder.^ 

Calcium  carbonate,  precipitated 100  parts. 

Orris  root    100  parts. 

Castile   soap    25  parts. 

Sodium  bicarbonate 25  parts. 

Myrrh  100  parts. 

Oil   of   wintergreen 10  parts. 


Lasar's  Tooth  Powder.* 

Calcium  carbonate,  precipitated 100  parts. 

Sodium  chlorid   2V2  parts. 

Pumice   stone    2^/^  parts. 

Castile   soap    3  parts. 

Oil  of  peppermint 1  part. 

Philadelphia  Dental  Dispensary  Tooth  Powder.' 

Calcium  carbonate,  precipitated 95  parts. 

Castile  ?oap    3  parts. 

Saccharin   14  part. 

Oil   of   birch 1  part. 

Oil  of  peppermint i/^  part. 

Miller's  Tooth  Powder.' 

Calcium   carbonate,    precipitated 30  parts. 

Magnesium  carbonate   10  parts. 

Orris  root    15  parts. 

Oil  of  peppermint %  part. 

Oxydizing  Tooth  Powder.' 
1. 

Calcium    carbonate,    precipitated 75  parts. 

Magnesium  carbonate  10  parts. 

Sodium   perborate    10  parts. 

Castile   soap    3  parts. 

Oil  of  peppermint 1  part. 

2. 

Calcium    carbonate,    precipitated 90  parts. 

Strontium  dioxid   8  parts. 

Castile   soap    3  parts. 

Oil  of   wintergreen 1  part. 

Oil  of  peppermint %  part. 


•N.    IJ.  —  Parts   as   used   in   these   prescriptions   mean   quantities   by   weiglit. 


306  pharmaco-therapeutics 

Cook's  Oxydizing  Tooth  Powder.^ 

Magnesium    oxid    50  parts. 

Calcium    carbonate,    precipitated 100  parts. 

Magnesium  dioxid   20  parts. 

Menthol    2  parts. 

Saccharin   1  part. 

Oil  of  peppermint 2  parts. 

Pedley's  Tooth  Powder.^ 

Calcium    carbonate,   precipitated 1,000  parts. 

Orris   root    250  parts. 

Castile  soap    125  parts. 

Boric  acid   125  parts. 

Phenol 30  parts. 

Oil  of  eucalyptus 25  parts. 

Red  Tooth  Powder.^ 

Red  tooth  powder  body 1,000  parts. 

Orris  root 300  parts. 

Sugar  of  milk 200  parts. 

Oil   of   cloves 50  drops. 

Oil    of    peppermint 50  drops. 

Fletcher's  Vegetol  Tooth  Powder.^ 

Pulverized  cereal 75  parts. 

Sodium  borate    18  parts. 

Potassium  chlorate 7  parts. 

Sweeten  with  saccharin  and  flavor  to  taste. 

Violet  Tooth  Powder.^ 

Violet  tooth  powder  body 650  parts. 

Sugar  of  milk 100  parts. 

Orris  root 200  parts. 

Licorice  root   25  parts. 

(Jumariu  14  part. 

Extract  of  jasmine 10  parts. 

Oil  of  rose 1  part. 

Tooth  Pastes. 

A  perfectly  satisfactory  tooth  paste  can  not  be  produced  with- 
out the  use  of  gelatin  or  mucilage  of  acacia.     Pastes  which  are 

'  N.  B. — Parts  as  used  in  these  prescriptions  mean  quantities  by  weight. 


PREPARATIONS   FOR   THE   MOUTH   AND   TEETH  307 

massed  with  pure  glycerin  are  disappointing;  the  latter  oozes 
from  the  tube,  discoloring  the  label  and  forming  an  unsightly 
package.  Glycerin  is  necessary,  but  it  should  not  be  employed 
alone.  Glucose  should  never  be  used  as  a  massing  fluid,  as  it 
will  easily  ferment.  The  consistency  of  the  excipient  or  massing 
fluid  determines  the  character  of  the  paste.  If  formaldehyd  solu- 
tion is  added  to  a  gelatin  massing  fluid,  the  latter  is  changed  to  an 
insoluble  compound. 

Massing  Fluids.^ 

Gelatin 1  part. 

Glycerin 30  parts. 

Water    35  parts. 

Soak  the  gelatin  in  the  water,  apply  gentle  heat  and  add  the 
glycerin. 

Another  massing  fluid  is  made  by  mixing: 

Glycerin 2  parts. 

Mucilage   of   acacia 2  parts. 

Mucilage  of  acacia  is  made  by  dissolving: 

Gum  arable    2  parts. 

Water 3  parts. 

Dissolve  the  gum  arabic  in  the  water,  and  strain  through  a 
fine  cotton  cloth. 

Tooth  pastes  may  be  prepared  according  to  this  general  formula  :^ 

Tooth  powder  body 10  parts. 

Massing  fluid 4  to  6  parts. 

The  paste  is  best  dispensed  in  collapsible  tubes  made  of  pure  tin. 
Miller's  Tooth  Paste.^ 

Calcium  carbonate,  precipitated 100  parts. 

Magnesium  carbonate    5  parts. 

Cuttlefish  bone 4  parts. 

Sugar 2  parts. 

Myrrh    2  parts. 

Massing  fluid enough  to  make  a  paste. 

*  N.  B. — Parts  as  used  in  these  prescriptions  mean  quantities  by  weight. 


308  PHARMACO-THERAPEUTICS 

KoLYNOS  Tooth  Paste.^   (Jenkins.) 

Soap 26  parts. 

Calcium  carbonate,  precipitated 20  parts. 

Alcohol    20  parts. 

,   Glycerin 25  parts. 

Citric  acid 2V2  parts. 

Oil  of  eucalyptus 2  parts. 

Oil  of  peppermint 2^/4  parts. 

Saccharin    i^^  part. 

Thymol    14  part. 


Saline  Tooth  Paste.^ 

Artificial  Carlsbad  salt 1  part. 

Powdered  Castile  soap 1  part. 

Calcium  carbonate,  precipitated ........       3  parts. 

Massing  fluid enough  to  make  a  paste. 

Tooth  Soaps. 

Hard  Tooth  Pastes  or  Tooth  Soaps. 

Tooth  soaps  are  usually  prepared  by  incorporating  about  20  per 
cent  of  Castile  soap  in  an  alcoholic  solution  into  the  powder  base 
and  pressing  the  mass  into  suitable  molds ;  their  hardness  increases 
with  age.  Tooth  soaps  are  usually  dispensed  in  flat  tin  boxes, 
china  jars,  or  wrapped  in  tin  foil. 

Austrian  Tooth  Soap.^ 

Castile    soap    200  parts. 

Calcium   carbonate,  precipitated 80  parts. 

Carmin 2  parts. 

Oil  of   peppermint 5  parts. 

Alcohol    30  parts. 

Bergmann's  Tooth  Soap.^ 

Transparent    glycerin    soap 50  parts. 

Sugar 25  parts. 

Alcohol    20  parts. 

Water 10  parts. 

Oil  of  peppermint 1  part. 

Dissolve  the  soap  and  sugar  in  the  alcohol. 

'  N.  B. — Parts  as  used  in  these  prescriptions  mean  quantities  by  weight. 


local  anesthetics  and  obtundents  309 

Kobert's  Tooth  Soap.^ 

Magnesium  carbonate 50  parts. 

Orris  root  '. 50  parts. 

Talcum    50  parts. 

Castile  soap    50  parts. 

Oil    of    wintergreen 3  parts. 

Thymol  Tooth  Soap.^ 

Pink  tooth  powder  body 750  parts. 

Castile  soap   200  parts. 

Glycerin 50  parts. 

Alcohol    100  parts. 

Thymol    10  parts. 

Cumarin Yo  part. 

Menthol   10  parts. 

Oil  of  cloves 5  parts. 

Dissolve  the  thymol,  cumarin,  menthol  and  oil  of  cloves  in  the 
alcohol,  add  the  glycerin  and  soap,  and,  after  complete  solution, 
incorporate  the  tooth  powder  body.  Press  in  suitable  molds,  ex- 
pose to  the  air  for  twenty-four  hours  and  paint  the  pieces  with 
tincture  of  benzoin   to   give   a  gloss   to   the   finished   product. 

LOCAL  ANESTHETICS  AND   OBTUNDENTS. 

Local  anestlieiics  (without  pain)  are  agents  which  are  em- 
ployed for  the  purpose  of  producing  insensibility  to  pain  in  a  cir- 
cumscribed area  of  tissue.  They  are  known  to  act  in  two  ways. 
Primary,  or  true  local,  anesthetics  are  those  which  act  at  once  on 
the  nerve  endings ;  and  secondary,  or  painful,  anesthetics  are  those 
which  are  preceded  in  their  anesthetic  action  by  a  period  of  in- 
tense irritation.  The  latter  group  is  principally  represented  by 
the  salts  of  the  alkalies  and  the  alkaline  earth  metals — potassium 
and  sodium  bromid,  etc.  Painful  anesthetics  are  not  employed  in 
the  form  of  hypodermic  injections.  Certain  essential  oils  which 
belong  to  the  group  of  painful  anesthetics  possess  valuable  obtund- 
ing  properties,  and  they  are  frequently  employed  for  such  pur- 
poses in  dentistry.  Specific  forms  of  local  anesthesia  may  also  be 
produced  by  paralyzing  the  sensory  ganglia  in  the  brain  or  in  the 
spinal  cord ;  these  methods  have,  however,  no  bearing  on  the  sub- 
ject under  consideration. 

Local  anesthetics  produce  insensibility  to  pain.  By  pain  we 
undferstand  the  conscious  manifestation  of  morbid  changes  within 


'  N.  B. — Parts  as  used  in  these  prescriptions  mean  quantities  by  weight. 


310  PHARMACO-THERAPEUTICS 

the  nerve  centers  caused  by  some  form  of  irritation.  At  present 
three  specific  sets  of  nerves  are  recognized  as  being  the  means 
.which  convey  the  sensation  of  cold,  of  heat,  and  of  pressure  and 
touch;  consequently  the  local  inhibition  of  the  functions  of  these 
three  sets  of  nerves  is  necessary  to  produce  insensibility  within 
a  circumscribed  area.  Local  anesthetics  must  be  absorbed  to  pro- 
duce their  typical  effect;  the  mucous  membranes  are  easily  pene- 
trated by  topically  applied  anesthetic  solutions,  and  superficial 
anesthesia  is  readily  produced.  The  horny  layer  of  the  skin  does 
not  allow  penetration;  endodermic  or  hypodermic  injections  are 
necessary  to  bring  the  anesthetic  solution  into  close  contact  with 
the  nerve  endings.  To  prevent  a  too  rapid  absorption  by  the  blood 
and  by  the  lymph  stream,  blocking  of  the  circulation  within  the 
injected  area  is  essential.  The  application  of  a  suitable  bandage 
applied  near  the  seat  of  the  anesthetic  field  and  the  injection  of 
powerful  vaso-constrictor  drugs  incorporated  in  the  anesthetic  so- 
lution are  both  effective.  To  prevent  unnecessary  damage  to  the 
cells,  the  solution  must  correspond  to  the  isotonic  index  of  the 
tissue  fluids. 

Circumscribed  areas  of  the  skin  and  accessible  parts  of  the 
mouth  may  be  locally  anesthetized  by  phj^sically  reducing  their 
temperature  by  abstracting  heat ;  agents  used  for  such  purposes  are 
termed  refrigerants.  A  protracted  warm  bath  is  frequently  of 
benefit  in  reducing  hypersensation  of  the  skin.  Protectives  ap- 
plied over  painful  wound  surfaces  act  to  some  extent  as  local 
anesthetics. 

Local  anesthesia,  according  to  Preyer's  conception,  is  produced 
as  follows:  Cocain  possesses  a  distinct  affinity  for  the  living 
protoplasm  of  the  nerve  cell ;  it  enters  with  it  into  a  labile  union, 
thus  producing  local  anesthesia,  which  lasts  until  this  temporary 
union  is  broken  up  by  releasing  the  chemical — not  as  the  original 
cocain,  however,  but  as  an  inert  compound  of  a  simpler  structure. 
In  other  words,  the  living  tissues  rid  themselves  of  the  poison  in 
some  unknown  manner.  In  dead  tissues  the  injected  cocain  will 
not  undergo  any  change. 

Numerous  instances  in  pharmacology  in  which  an  alcohol  radical  in  an  ester- 
like  combination  with  an  acid  is  required  to  bring  about  any  specific  effect 
may,  according  to  Pauli,i  be  explained  in  this  way: 

"The  alcohol  radical  only  renders  the  ready  absorption  of  the  substance  by 


»Pauli:    Physical    Chemistry   in   the    Service   of   Medicine,    1907,   p.   96. 


LOCAL   ANESTHETICS   AND    OBTUNDENTS  311 

the  cell;  the  anion  connected  with  it  is  the  real  active  principle.  Cocain  is, 
for  example,  a  methyl  ester-benzoyl-ecgonin,  a  substituted  tropincarbonic  acid. 
The  benzoyl-ecgonin,  the  real  carrier  of  the  medicinal  property,  is,  however, 
twenty  times  less  poisonous  than  its  ester,  cocain,  and  does  not  possess  the 
anesthetic  properties  of  the  latter.  Only  after  being  converted  into  an  ester, 
through  any  alcohol  whatsoever,  is  the  cocain  effect  produced.  Existence  in 
the  form  of  an  ester  is  apparently  always  the  sine  qua  non  of  a  useful  local 
anesthetic  whose  active  anion  must  enter  the  endings  of  the  sensory  nerves. 
Einhorn  has  found  that  a  large  number  of  cyclic  and  heterocyclic  esters  are 
liable  to  bring  about  a  local  anesthesia,  and  has  been  able  to  discover  valu- 
able substitutes  for  cocain  in  the  orthoforms,  which  represent  methyl  esters  of 
amido-oxybenzoic  acid,  and  in  nirvanin,  a  diethylglycocoll  compound  of  ortho- 
form.  Eucain  and  anesthesin  are  also  esters,  the  latter  one  of  a  p-amido- 
benzoic  acid.  We  being  directly  concerned  in  the  physiologic  effect  produced, 
the  presence  of  an  alcohol  radical  in  the  compound  first  renders  such  an  effect 
possible,  for  only  under  these  circumstances  is  the  active  ion  present  in  suffi- 
cient concentration  at  its  point  of  physiologic  contact." 

Local  anesthesia  is  indicated  in  all  minor  and  in  relatively  many 
major  operations  on  the  mucous  surfaces,  the  skin,  and  the  teeth. 
Certain  reflex  disturbances — vomiting  from  an  irritated  stomach 
or  hyperesthesia  of  the  mucous  membrane  of  the  mouth  during 
taking  of  an  impression,  and  many  forms  of  neuralgia — are  fre- 
quently benefited  by  the  application  of  local  anesthetics.  Observa- 
tions made  by  Spiess,^  Rosenbach,^  Fischer^  and  Kirchner*  have 
fully  demonstrated  the  therapeutic  value  of  local  anesthetics  in  the 
abortive  treatment  of  inflammation.  Inflammation  in  its  early 
stages,  according  to  Spiess,  may  be  completely  aborted  if  it  is  pos- 
sible to  prevent  the  occurrence  of  pain.  Spiess  applies  local  anes- 
thetics on  the  seat  of  inflammation,  while  Rosenbach  advocates 
general  analgesics,  such  as  morphin,  for  this  purpose.  The  ad- 
vantages of  local  therapeutic  applications  in  dental  surgery  for 
the  above  purposes  is  apparent,  and  Fischer  and  Kirchner  have 
frequently  made  use  of  Spiess'  suggestion.  The  beneficial  influ 
ence  of  local  anesthetics  on  inflammatory  processes  are  explained 
by  Spiess  as  follows:  When  the  exposed  nerve  fibers  are  brought 
in  direct  contact  with  the  anesthetic,  they  become  at  once  insensible, 
but  the  anesthetic  must  not  interfere  with  the  blood  vessels — they 
must  not  act  as  vaso-constrictors.     The  important  factor  in  this 

'  Spiess:  Munchener  Medizinische  Wochenschrift,  1906,  No.  8. 
*  Rosenbach:  Munchener  Medizinische  Wochenschrift,  1906,  No.  18. 
•Fischer:  Deutsche  Monatsschrift  fur  Zahnheilkunde,   1907,  No.  4. 
♦Kirchner:  Deutsche  Zahnarztliche  Wochenschrift,  1907,  No.  28. 


312  PHARMACO-TIIERAPEUTICS 

treatment  seems  to  be  to  bring  and  to  hold  the  local  anesthetic  m 
close  contact  Avith  the  wound  surface  until  all  subjective  pain  is 
more  or  less  abolished,  and  to  keep  the  wound  surface  in  this 
analgesic  state.  Cocain,  as  it  possesses  marked  vaso-constrictor 
power,  is  not  well  adapted  for  this  purpose,  but  novocain,  made 
into  a  paste  with  water  and  placed  on  the  painful  wound  surface, 
apparently  materially  enhances  the  progress  of  wound  healing. 
Fischer  and  Kirchner  recite  a  number  of  cases  in  which  this  treat- 
ment has  been  applied  with  marked  benefit  to  painful  sockets  af- 
ter tooth  extraction.  These  statements  are  fully  corroborated 
hj'  our  own  observations.  Novocain,  being  free  from  all  irritation 
to  soft  tissues,  is  preferably  employed  instead  of  orthoform ;  the 
latter  has  been  recommended  for  the  above  purposes  for  some  time 
past,  but  when  it  is  used  too  freely  it  is  liable  to  produce  slough- 
ing of  the  tissues. 

Local  anesthesia  is  not  a  substitute  for  general  anesthesia ;  its 
usefulness  is  materially  increased  by  familiarizing  one's  self  with 
the  modern  methods  of  its  production  and  with  a  perfect  mastering 
of  the  technique.  The  danger  of  poisoning  has  been  practically 
eliminated  by  using  isotonic  solutions  containing  a  relatively  small 
percentage  of  the  anesthetic  in  combination  with  the  alkaloid  of 
the  suprarenal  capsule.  Even  if  the  danger  of  general  narcosis  is 
small  under  the  very  best  conditions,  the  danger  from  local  anes- 
thesia is  alwaj^s  less.  The  greater  majority  of  all  dental  operations 
can  be  safely  carried  out  under  local  anesthesia,  provided  the 
operator  has  acquired  a  complete  working  knowledge  of  the  various 
components  which,  as  a  whole,  constitute  this  important  branch  of 
dental  therapeutics. 

For  the  sake  of  convenience,  local  anesthetics  are  divided  into: 

1.  Soluble  local  anesthetics. 

2.  Insoluble  local  anesthetics. 

3.  "Refrigerant  local  anesthetics. 

Soluble  Local  Anesthetics. 

Cocain  Hydrochlorid  ;  CocAiNiE  Hydrochloridum,  U.  S.  P.,  B. 
P.;  C17H21NO4HCI ;  Methyl-benzoyl-eggonin ;  Chlorhydrate 
DE  Cocaine,  F.  ;  Salzsaures  Kokain,  G. 

Source  and  Character.— It  is  the  hydrochlorid  of  the  alkaloid 
cocain  obtained  from  seveial  varieties  of  Coca.    It  appears  in  color- 


LOCAL   ANESTHETICS   AND   OBTUNDENTS  313 

less  crystalline  flakes  or  scales,  or  as  a  white  crystalline  powder, 
odorless,  having  a  saline,  slightly  bitter  taste,  and  producing  on 
the  tongue  a  tingling  sensation,  followed  by  numbness.  It  is 
soluble  in  0.4  parts  of  water,  2.6  parts  of  alcohol,  18.5  parts  of 
chloroform,  and  in  glycerin ;  it  is  readily  soluble  in  hot  water,  but 
insoluble  in  ether,  petroleum  benzin,  and  olive  oil.  It  melts  at 
about  375°  F.  (190°  C).  Its  aqueous  solution  reacts  neutral  to 
litmus  paper.  Prolonged  heating  of  the  salt  or  its  solution  decom- 
poses it  into  methyl-alcohol,  benzoic  acid,  and  ecgonin.  It  is  in- 
compatible with  alkaline  hydrates  or  carbonates,  salicylates,  ben- 
zoates,  bromids,  iodids,  the  mercury  salts,  and  silver  nitrate. 

Cocain  solution  may  be  preserved  for  a  reasonable  length  of 
time  by  adding  to  it  I/2  P^i'  cent  boric  acid,  or  by  making  the  solu-' 
tion  with  camphor  water.  INIercuric  chlorid  can  not  be  added  for 
this  purpose,  as  it  will  combine  with  cocain,  forming  a  double  salt. 
Fractional  sterilization  of  the  solution  is  serviceable;  it  is  accom- 
plished by  using  the  autoclave  and  subjecting  the  solution  to  ITG** 
F.  (80°  C.)  for  twenty  minutes  at  a  time  on  three  successive  days. 

The  coca  plant,  Erythroxylon  coca,  is  principally  found  in  Peru  and  Bolivia, 
where  it  has  been  cultivated  from  time  immemorial.  It  has  played  an  im- 
portant mission  in  the  religious  and  political  life  of  the  aborigines.  The  coca 
plant  is  regarded  by  the  Indians  of  South  America  as  a  divine  gift,  which 
"satisfies  the  hungry,  strengthens  the  weak,  and  supplies  new  vitality  to  the 
exhausted,  while  the  unhappy  are  made  to  forget  their  troubles."  The  Inkas 
restricted  to  the  royal  families  the  right  to  cultivate  and  use  the  coca  leaves. 
With  the  conquest  of  Peru  by  Pizarro  (1532)  the  Spanish  first  monopolized 
and  later  levied  a  heavy  tax  on  coca  leaves,  which  became  a  rich  source  of 
income  to  the  Spanish  crown.  The  aborigines  of  South  America  chew  the  coca 
leaves  mixed  with  alkalies,  usually  wood  ashes,  to  facilitate  the  ready  solution 
of  the  alkaloids.  The  stimulating  action  of  the  cocain,  which  makes  them  en- 
dure greater  physical  labor  and  elude  temporarily  the  necessity  of  sleep,  is 
well  known  to  the  South  American  Indians;  they  are  also  acquainted  with  the 
dangers  of  its  too  free  indulgence.  The  small  green  or  greenish-brown 
leaves  of  the  coca  plant  are  plucked  from  the  shrub,  dried  in  the  sun,  and 
immediately  packed  for  shipment.  Niemann  and  Lossen,  working  in  Woh- 
lere's  laboratory  in  Gottingen,  were  the  first  to  isolate  cocain.  Later  on  it 
was  synthetically  prepared  by  Merck,  Liebermann,  and  Giesel.  The  first  records 
of  the  anesthetic  properties  of  cocain  were  published  by  Scherzer,  followed  by 
Niemann  (1860)  and  otheis.  Von  Anrep,  in  1878,  published  the  first  de- 
tailed report  of  its  definite  local  anesthetic  properties  on  the  eye  and  other 
tissues.  It  remained  for  Roller,  however,  to  introduce  it  permanently  into 
surgery  through  his  communication  addressed  to  the  Ophthalmologic  Congress 
held  in  Heidelberg  in  1884.     Cocain  was  now  readily  accepted  by  the  profes- 


314  PHARMACO-THERAPEUTICS 

sion  at  large,  and  very  soon  it  became  the  most  important  drug  for  the  pur- 
pose of  producing  local  anesthesia. 

As  dental  surgery  has  to  deal  so  much  with  pain,  it  is  not  at  all 
surprising  that  eocain  has  been  so  quickly  admitted  to  this  spe- 
cial field  of  surgery.  Hillischer  published  his  experiments  in  1884, 
which  were  soon  followed  by  Hughes,  Audina,  David,  Barker,  and 
others.  The  most  complete  essays  on  the  use  of  eocain  in  dentistry, 
which  materially  assisted  in  making  the  drug  widely  known  in 
dental  circles,  were  published  in  1886.  Adolph  Witzel,  of  Essen, 
presented  a  valuable  contribution  in  German,  which  was  followed 
a  few  months  later  by  a  similar  essay  bj'^  George  Viau,  of  Paris. 
Witzel  advocated  a  20  per  cent  solution,  using  one  grain  of  co- 
•cain  of  a  questionable  purity  for  one  injection.  It  is  surprising, 
indeed,  that  not  more  serious  intoxications  from  such  enormous 
concentrations  and  quantities  have  occurred.  (See  Local  Anes- 
thesia.) 

Average  Dose. — 14  grain  (0.015  Gm.). 

Preparations. — 

Cocain  PJienate;  Cocaince  Pkenolis;  Phenol-Cocain;  Cocain  Car- 
bolate.  It  represents  semi-solid,  almost  colorless,  partly  crystalline 
masses,  and  is  soluble  in  alcohol  and  ether,  but  insoluble  in  water. 

Fluidextract  of  Coca;  Fluidextr actum  Cocce,  U.  S.  P. ;  Extractum 
Cocce  Liquidiim,  B.  P.    Average  dose,  30  minims  (2  C.c). 

Wine  of  Coca;  Vinum  Cocce,  U.  S.  P.  Average  dose,  4  fluidrams 
(16  C.c). 

Oleate  of  Cocain;  Oleatum  Cocaince,  U.  S.  P.  It  contains  5  per 
cent  of  the  alkaloid. 

Neurocain  is  a  special  term  given  to  small  readily  soluble  billets 
composed  of  pure  cocain  hydrochlorid,  weighing  ^2  grain  each. 

Therapeutics. — Cocain  is  principally  used  as  a  local  anesthetic, 
especially  for  operative  purposes,  and  rarely  as  a  curative  agent. 
Anesthetization  in  minor  surgery,  and  in  surgical  interferences 
with  the  eye,  external  ear,  nose,  throat,  and  the  oral  cavity,  de- 
pends almost  exclusively  on  cocain  and  its  substitutes.  On  mucous 
linings  it  is  frequently  applied  topically,  but  for  deeper  anesthesia 
hypodermic  injection  is  necessary.  The  latter  is  usually  prepared 
by  adding  to  a  physiologic  salt  solution  sufficient  cocain  hydro- 
chlorid to  make  a  1  per  cent  solution.     (See  Local  Anesthesia.) 

Cocain  is  a  protoplasm  poison,  producing  typical  effects  when- 
ever it  is  brought  in  contact  with  the  living  tissue.     It  causes  pro- 


LOCAL   ANESTHETICS    AND   OBTUNDENTS  315 

nounced  constriction  of  the  smaller  vessels,  resulting  in  anemia  of 
the  affected  area.  Its  specific  action  is  manifested  by  paralyzing 
the  sensory  nerve  endings  without  primary  irritation.  On  the 
skin  it  has  no  action,  but  when  injected  into  it,  or  when  absorbed 
from  the  mucous  membranes,  its  anesthetic  action  is  quickly  pro- 
duced. The  anesthesia  lasts  as  long  as  the  cocain  remains  in  di- 
rect contact  with  the  nerve  endings;  about  fifteen  minutes  is  the 
average  time  of  an  anesthesia  produced  by  y^  cubic  centimeter  of  a 
1  per  cent  solution  injected  into  normal  tissues.  The  anesthesia 
diminishes  with  the  absorption  of  the  cocain  by  the  body  fluids. 
The  production  of  anesthesia  depends  on  the  decomposition  of  the 
cocain. 

The  average  concentration  of  a  solution  for  anesthetic  purposes 
to  be  used  in  the  gum  tissue  should  be  1  per  cent.  The  other 
tissues  of  the  oral  capacity  are  readily  anesthetized  by  a  i/^  per  cent 
solution.  If  a  cocain  solution  is  injected  so  as  to  encircle  a  nerve 
trunk,  anesthesia  of  the  sensory  fibers  of  the  entire  trunk  is  pro- 
duced— regional  anesthesia.  By  injecting  cocain  solution  into  the 
spinal  canal,  a  complete  anesthesia  of  the  sensory  as  well  as  of  the 
motor  centers  (the  latter  only  transitory)  is  produced,  lasting  from 
one  to  two  hours — spinal  anesthesia.  Cocain  is  quickly  absorbed 
by  the  tissues  and  carried  away  by  the  blood,  resulting  in  intense 
disturbances  of  the  central  nervous  system.  Small  doses  produce 
a  rapid  pulse  and  increase  the  respiration,  while  large  doses  para- 
lyze the  centers  of  respiration. 

Toxicology. — The  typical  picture  of  cocain  poisoning  is  pro- 
duced when  the  blood  flowing  through  the  central  nervous  system 
contains  a  sufficient  quantity  of  the  drug,  even  for  the  moment 
only,  which  is  dangerous  to  this  organ.  No  maximum  dose  of  co- 
cain can  be  positively  established ;  this  is  equally  true  of  chloro- 
form and  ether  when  used  for  general  anesthetic  purposes.  The 
many  cases  of  so-called  idiosyncrasy  probably  find  an  explanation 
in  the  too  large  doses  which  formerly  were  so  frequently'  adminis- 
tered. 

The  danger  of  poisoning  with  cocain  preparations  has  been 
practically  eliminated  with  our  increased  knowledge  of  its  action 
on  the  tissues.  At  present  solutions  containing  a  relatively  small 
percentage  combined  with  epinephrin  are  usually  employed,  and, 


316  PHARMACO-THERAPEUTICS 

when  injected  with  the  proper  technique,  dangerous  results  are 
comparatively  rare.    No  direct  antidotes  of  cocain  are  known. 

The  treatment  of  general  intoxication  is  purely  symptomatic. 
Anemia  of  the  brain,  which  is  of  little  consequence,  may  be  readily 
overcome  by  placing  the  patient  in  a  recumbent  position,  or  by 
complete  inversion  if  necessary.  As  a  powerful  dilator  of  the 
peripheral  vessels,  the  vapors  of  amyl  nitrite^  are  exceedingly 
useful;  it  is  best  administered  by  placing  3  to  5  drops  of  the 
fluid  on  a  napkin  held  before  the  nostrils  for  inhalation.  Flush- 
ing of  the  face  and  an  increase  in  the  frequency  of  the  pulse  fol- 
lows almost  instantly.  Nausea  may  be  remedied  by  administering 
small  doses  of  spirit  of  peppermint,  aromatic  spirit  of  ammonia,  or 
validol.  The  latter  is  a  compound  of  menthol  and  valerianic  acid, 
and  deserves  special  recommendation.  To  overcome  the  disturb- 
ances of  respiration,  quickly  instituted  artificial  respiration  is 
the  alpha  and  omega  of  all  methods  of  resuscitation ;  the  only  drug 
that  has  proved  to  be  of  clinical  value  in  this  connection  is  strych- 
nin in  the  form  of  the  sulphate  or  the  nitrate  in  full  doses  by  means 
of  hypodermic  injections. 

CocAiNiSM. — The  repeated  administration  of  cocain  may  readily 
establish  an  addiction  to  this  drug,  known  as  cocainism  or  cocain 
habit.  The  exhilarating  effect  of  cocain  on  the  nervous  system, 
euphoria,  is  largely  responsible  for  the  craving  for  the  drug.  The 
treatment  of  chronic  morphinism  by  substituting  cocain  for  the 
former  drug  often  results  in  developing  an  irresistible  desire  for 
cocain  or  for  both  alkaloids.  Cocain  habitues  are  very  insistent 
upon  the  mode  of  administration  of  the  poison.  Whether  they  take 
this  drug  by  insufflation  or  by  injection,  or  even  by  the  rectum, 
they  will  always  strenuously  insist  upon  the  particular  method 
they  originally  adopted.  Usually  the  hypodermic  injection  is 
preferred  by  the  white  race,  while  the  negro  prefers  to  snuff  his 
cocain.  The  continuous  puncturing  with  the  needle  in  injecting 
cocain  into  the  tissues  produces  an  injurious  effect  on  the  skin  in 
the  cocain  habitue;  abscesses  form,  and  the  resulting  scars  fre- 
quently cover  all  available  spaces  of  the  body,  especially  the  arms 
and  the  legs.  Cocainism  usually  manifests  itself  in  disturbed  di- 
gestion, salivation,  and  emaciation,  the  most  important  changes 


*  For  convenience,   amyl   nitrite   may   be   procured   in   sm.all   glass   capsules   holding   the 
necessary  quantity  for  one  inhalation. 


LOCAL   ANESTHETICS    AND    OBTUNDENTS  317 

occurring  in  the  nervous  system.  Sleeplessness  and  tremors,  and 
occasionally  convulsions,  hallucinations,  insanity,  and  delirium, 
have  been  noted  after  long  abuse,  along  with  indefinite  disturbances 
of  sensation  and  motion. 

While  the  addiction  to  cocain  is  very  appalling,  cocainism  ap- 
parently yields  readily  to  treatment.  Sanitarium  treatment,  with 
the  proper  medical  care,  is  the  most  efficient  method  for  the  eradi- 
cation of  the  habit. 

Local  Anesthetic  Solution. 

R     Cocaiiiae  hydrochloridi  gr.  v   (0.32  Gm.) 

Sodii  chloridi  gr.  iv   (0.25  Gm.) 

AqusG  destillat.  flS  j   (30  C.c.) 

M. 

Sig. :     Cocain  injection  for  dental  purposes.     To  each  cubic 
centimeter  add  1  drop  of  epinephrin  solution  when  used. 

Local  Obtundent. 

fli     Cocaiuse  hydrochloridi  gr.  xv   (1.0  Gm.) 

Phenolis  liquid.  3  j    (4  C.c.) 

M. 

Sig.:     Apply  the  heated  solution  to  hypersensitive  dentin. 

(Jenkins.) 

Novocain  ;  Novocaina  ;  P-aminobenzoyldiethylaminoethanol 
Hydrochloride  CeH^.NH^.COa.CaH^.  ^'(CaHJa.HCl. 

Source  and  Character. — Novocain  is  the  hydrochloric  salt  of 
a  synthetically  prepared  alkaloid,  the  methyl  ester  of  p-amino-ben- 
zoic  acid.  It  is  a  white  crystalline  powder,  or  colorless  needle- 
shaped  crystals,  melting  at  263°  F.  (156°  C).  It  may  be  heated 
to  200°  F.  (120°  C.)  without  decomposition.  It  dissolves  in  an 
equal  amount  of  cold  water,  the  solution  having  a  neutral  char- 
acter; in  cold  alcohol  it  dissolves  in  the  proportion  of  1  to  30. 
Caustic  alkalies  and  alkaline  carbonates  precipitate  the  free  base 
from  the  aqueous  solution  in  the  form  of  a  colorless  oil,  which  soon 
solidifies.  It  is  incompatible  with  the  alkalies  and  alkaline  car- 
bonates, with  picric  acid,  and  the  iodids. 

Average  Dose. — Yi  gi'ain  (0.03  Gm.). 

Therapeutics. — Novocain  is  a  local  anesthetic,  possessing  the 
same  action  on  the  peripheral  nerves  as  cocain,  with  an  equal 
amount  of  anesthetic  potency.     Applied  locally,  it  is  nonirritating 


318  FHARMACO-THERAPEUTICS 

to  the  soft  tissues.  In  conjunetion  with  epinephrin,  it  does  not 
reduce  the  vaso-constrictor  properties  of  the  latter ;  on  the  contrary, 
it  increases  them  to  some  extent.  The  indications  for  novocain  are 
the  same  as  those  for  cocain.  For  hypodermic  injections  for  dental 
purposes  it  is  used  in  a  2  per  cent  solution,  with  the  addition  of 
small  quantities  of  epinephrin.  (See  Local  Anesthesia.)  To  re- 
lieve painful  conditions  of  wound  surfaces  or  of  a  tooth  socket, 
novocain,  when  placed  or  packed  against  such  surfaces,  will  quick- 
ly relieve  pain. 

Toxicology. — Novocain  is  about  six  times  less  poisonous  than 
cocain.  As  much  as  4  grains  (0.26  Gm.)  have  been  injected  with 
no  ill  results.  LiebP  injected  in  his  own  body  6  grains  (0.4  Gm.) 
of  novocain,  and  an  hour  after  the  anesthetization  had  passed  off 
he  again  injected  12  grains  (0.8  Gm.)  in  a  10  per  cent  solution. 
Slight  intoxication  followed,  accompanied  by  optic  disturbances, 
deafness,  loss  of  energy,  and  headache.  In  one  hour  and  a  half  all 
the  symptoms  had  disappeared,  without  leaving  any  after  effects. 

Novocain  intoxication  presents  very  much  the  same  symptoms  as 
those  produced  by  cocain,  with  this  one  important  exception:  its 
absolute  toxicity  is  about  six  times  less  than  that  of  cocain. 
Furthermore,  it  should  be  remembered  that  a  definite  synthetic 
product  is  always  more  reliable  concerning  its  composition  and 
chemic  purity  than  an  alkaloid  from  an  animal  or  vegetable  source. 

Local  Anesthetic  Solution. 

IJ     Novocaini  gr.  x   (0.6  Gm.) 

Sodii  chloridi  gr.  iv   (0.25  Gm.) 

Aquae  destillat.  flj  j   (30  C.c.) 

M. 

Sig.:     To  each  cubic  centimeter  add  1  drop  of  epinephrin 
solution  when  used. 

Tropa-Cocain  HydrocJilorid.  It  was  discovered  by  Giesel,  in 
1891,  in  the  leaves  of  the  Japanese  coca  plant.  In  1902  Lieber- 
mann  prepared  it  synthetically.  It  is  very  readily  soluble  in 
water,  and  its  solutions  may  be  boiled  Avithout  decomposition,  and 
they  possess  slight  antiseptic  properties.  It  is  used  in  2  to  5  per 
cent  solutions;  its  anesthetizing  power  is  less  than  that  of  cocain. 
Its  action  is  quick,  but  of  a  short  duration.      If    combined    with 

*Liebl:  Munchener  Medizinische  Wochenschrift,  1906,  No.  SO. 


LOCAL   ANESTHETICS   AND    OBTUNDENTS  319 

epinephrin,  it  will  almost  completely  destroy  the  vaso-constrictor 
power  of  the  latter. 

Eucain  A  and  B.  They  are  respectively  the  hydrochlorids  of 
synthetic  derivations  of  triacetonamin  and  of  vinyl-diacetonal- 
kamin.  Eucain  B,  U.  S.  P.  is  now  exclusively  used.  It  is  a  white 
crystalline  powder,  soluble  in  20  parts  of  water.  Its  solutions  may 
be  boiled  without  decomposition ;  they  are  slightly  antiseptic.  It  is 
about  three  and  a  half  times  less  poisonous  than  cocain,  but  less 
active  than  the  latter.  Wjhen  combined  with  epinephrin  it  par- 
tially destroys  the  vaso-constrictor  power  of  the  latter. 

Holocain  HydrocJilorid.  It  is  prepared  by  combining  phenac- 
etin  and  phenetidin;  it  is  soluble  in  40  parts  of  water,  and  easily 
decomposed  by  alkalies.  Solutions  may  be  sterilized  by  boiling. 
Holocain  injections  produce  severe  irritation. 

Acoin  HydrocJilorid.  It  is  a  synthetic  compound  of  the  alkyl- 
oxyphenyl-guanidin  group,  and  is  related  to  holocain.  It  is  a 
white  crystalline  powder,  soluble  in  15  parts  of  water  and  very 
soluble  in  alcohol.  Its  solutions  are  readily  decomposed  by  alka- 
lies ;  they  are  very  strongly  antiseptic.  It  is  a  powerful  local  anes- 
thetic of  lasting  potency,  but  is  much  more  poisonous  than  cocain. 
Its  solution  is  strongly  irritating  to  the  tissues. 

Nirvanin.  It  is  a  synthetic  product  of  the  orthoform  group,  dis- 
covered by  Einhorn  in  1898.  It  is  a  white  powder,  readily  soluble 
in  water ;  it  may  be  sterilized  by  boiling.  It  is  employed  in  from  1 
to  5  per  cent  solutions ;  its  injection  is  painful.  While  it  is  less 
toxic  than  cocain,  its  anesthetizing  potency  is  also  decidedly  much 
less. 

Stovain.  It  is  a  derivative  of  the  amino  alcohol  group.  It  was 
discovered  by  Fourneau  in  1904,  and  introduced  into  materia 
medica  by  Billon.  Keclus  recommended  it  highly  as  a  local  anes- 
thetic. It  is  a  crystalline  white  powder,  readily  soluble  in  water, 
with  a  distinct  acid  reaction,  causing  pain  when  injected,  and  pos- 
sibly necrosis  when  employed  in  concentrated  solution.  Its  solu- 
tions may  be  boiled ;  they  are  slightly  antiseptic.  Stovain  is  about 
half  as  toxic  as  cocain,  and  may  be  used  in  V2  to  1  per  cent  solu- 
tion. Combined  with  epinephrin  it  partially  destroys  the  action  of 
the  latter. 

Alypin.  Chemically  it  is  closely  related  to  stovain,  being  syn- 
thetically prepared  from  the  same  source.    It  is  very  readily  solu- 


320  PHARMACO-THERAPEUTICS 

ble  in  water;  its  solutions  may  be  boiled,  and  they  react  neutral 
to  litmus  paper.  It  is  less  toxic  than  cocain,  and  possesses  about 
the  same  anesthetizing  power,  which  is,  however,  of  less  duration. 
It  is  strongly  irritating  to  the  tissues,  and  in  5  per  cent  solution 
may  cause  necrosis.  In  combination  with  epinephrin  it  will  neu- 
tralize the  vaso-constrictor  power  of  the  latter  to  some  extent. 

Nervocidin.  It  is  the  hydrochlorid  of  an  alkaloid  obtained  from 
an  exotic  plant  of  India  known  as  Gasu-Basu,  and  introduced  into 
materia  medica  by  Dalma.  It  is  a  light-yellowish,  very  hygro- 
scopic powder,  readily  soluble  in  water.  It  can  not  be  used  for 
hypodermic  injection,  as  it  is  strongly  irritating.  It  is  recom- 
mended for  anesthetizing  the  dental  pulp ;  its  mode  of  application 
for  such  purposes  is  similar  to  the  one  used  for  arsenic  trioxid,  and 
it  deserves  to  be  tried  in  cases  where  arsenic  is  contraindicated. 
The  introduction  of  pressure  anesthesia  for  the  removal  of  the 
dental  pulp  has  largely'  dispensed  with  the  use  of  nervocidin. 

Chlorhutanol.  It  is  also  known  as  aceton-chloroform,  chloretone, 
or  in  a  1  per  cent  solution  as  aneson,  or  anesin.  It  is  a  tri-chlor- 
tertiary  butyl  alcohol,  forming  white  crystals  and  having  a  cam- 
phoraceous  odor.  It  is  very  soluble  in  chloroform,  aceton,  alcohol, 
and  ether,  and  to  the  extent  of  less  than  1  per  cent  in  water.  Its 
solutions  may  be  sterilized  by  boiling,  and  they  possess  antiseptic 
properties.  Regarding  its  anesthetizing  power,  it  is  much  weaker 
than  cocain. 

QuiNiN  AND  Urea  Hydrochlorid. 

Quinin  and  urea  hydrochlorid,  C2oH2,N202.HCl+CH,N20.HCl+ 
5H2O,  is  a  chemical  compound  of  quinin  hydrochlorid  and  urea 
hydrochlorid,  also  known  as  carbaminated  quinin  bihydrochlorid. 

At  ordinary  temperature  the  salt  dissolves  in  its  own  weight  of 
water  with  a  marked  lowering  of  temperature;  its  solution  reacts 
strongly  acid.  The  concentrated  solution  has  a  straw-colored  ap- 
pearance. The  salt  is  not  hygroscopic  and  is  unalterable  in  the  air. 
It  fuses  at  about  167°  F.  (75°  C.)  into  a  yellow  liquid,  which  con- 
geals on  cooling  into  a  yellow  mass,  with  about  10  per  cent  loss  of 
water  of  crystallization.  It  is  also  readily  soluble  in  alcohol  but 
only  sparingly  in  chloroform.  Solutions  of  quinin  and  urea  hydro- 
chlorid can  be  boiled  without  alteration,  but  they  readily  decompose 
on  standing.     They  are  slightly  antiseptic  and  are  tolerant  to  the 


LOCAL   ANESTHETICS    AND    OBTUNDENTS  321 

addition  of  ordinary  doses  of  epinephrin.  For  dental  hypodermic 
injections,  it  is  usually  employed  in  a  2  per  cent  solution,  using  a 
physiologic  salt  solution  as  a  base. 

The  anesthetic  action  of  quinin  does  not  specificially  affect  the 
peripheral  ends  of  the  motor  or  sensory  nerves.  When  brought  in 
contact  with  the  human  blood  the  poisonous  nature  of  the  quinin 
completely  arrests  the  amoeboid  movements  of  the  leucocytes,  which 
assume  a  darker  color,  and  finally  break  up  into  granular  debris. 
Quinin  is  a  protoplasm  poison  which  in  due  time  kills  the  tissue 
cell.  The  prolonged  analgesia,  which  remains  for  hours,  and  when 
enough  of  the  injection  has  been  absorbed,  even  days,  finds  an  ex- 
planation in  the  coagulation  of  the  protoplasm.  Hertzler  states 
that  "when  infiltration  takes  place,  anesthesia  lasts  from  several 
days  to  two  weeks  or  longer."  More  or  less  persistent  induration 
follows  the  injection;  it  may  be  traced  to  an  exudate  of  fibrinous 
material  into  the  infiltrated  tissues,  resulting  in  an  edema  which 
may  last  for  weeks.  The  absorption  of  the  injected  quinin  solu- 
tion, even  when  physiologic  salt  solution  is  used  as  a  base,  is  slow. 
If  the  tissues  are  incised  immediately  after  the  injection,  the  solu- 
tion escapes  into  the  wound,  and  the  resultant  anesthesia  is  com- 
paratively light.  Under  such  conditions,  wound-healing  is  ap- 
parently not  interfered  with,  while  if  the  solution  be  allowed  to 
remain  until  it  is  absorbed,  wound-healing  is  decidedly  retarded 
and  occasionally  produces  necrosis.  When  applied  topically  upon 
the  mucous  surfaces  of  the  mouth  in  concentrated  solution  it  seems 
to  have  no  anesthetic  effect;  the  solution  is  only  very  slowly  ab- 
sorbed. Hemorrhage  seems  to  be  very  little  interfered  with  in  the 
early  stages  of  anesthesia;  after  complete  absorption  has  taken 
place  there  is  to  be  observed  a  slight  check  in  the  flow  of  blood. 
Urea  hydrochlorid,  which  is  added  to  quinin  hydrochlorid  in  the 
preparation  of  this  compound,  has  apparently  no  physiologic  ef- 
fect on  the  tissues  in  the  comparatively  small  doses  in  which  it  is 
employed;  its  sole  purpose  is  to  render  the  rather  sparingly  solu- 
ble quinin  hydrochlorid  (about  1:34)  more  soluble.  Urethan,  anti- 
pyrin,  and  other  bodies  exercise  a  similar  action  on  the  salt. 

Quinin  and  urea  hydrochlorid,  when  employed  as  a  local  anes- 
thetic in  dental  operations,  possesses  no  advantage  but  many  disad- 
vantages as  compared  to  novocain.    While,  a  priori,  its  non-poison- 


322  PHARMACO-THERAPEUTICS 

ous  nature  indicates  safety,  this  safety  is  only  relative  as  it  refers 
to  larger  doses.^ 

Anesthetic  Solutions  for  the  Dental  Pulp. 
I. 

IJ     Chloretoni 

Caraphorae  fl3   ij    (8   C.c.) 

01.  caryophylli  aa  3  ss    (2.0  Gm.) 

M. 

Sig. :     Saturate  a  pledget  of  cotton  and  place  it  upon  the 
aching  pulp. 

u. 
IJ     Camphorsez  3  jss  (6  Gm.) 

Chloralis  hydrat.  3  iij    (12  Gm.) 

Novocainse  gr.  xlv   (3  Gm.) 

M. 

Sig.:     Saturate  a  pledget  of  cotton  and  place  it  upon  the 
aching  pulp. 

Insoluble  Local  Anesthetics. 

A  number  of  synthetic  compounds  have  been  introduced  within 
recent  years  which  possess  marked  analgesic  power  when  applied 
in  substance  on  painful  mucous  membranes  or  abraded  surfaces. 
They  are  only  slightly  soluble  in  water  and  in  the  body  fluids,  and 
consequently  they  are  not  poisonous.  Some  of  these  compounds 
are  slightly  irritating  to  the  soft  tissues.  They  are  usually  pre- 
scribed in  the  form  of  dusting  powders  or  ointments. 

OrtJioform  and  OrtJioform  New.  Both  are  synthetic  compounds 
prepared  from  aromatic  amino-oxy-esters,  forming  grayish 
powders.  They  are  antiseptic,  insoluble  in  water,  and  conse- 
quently are  slowly  absorbed  by  the  tissues;  they  are  not  used  for 
hypodermic  injections.  They  are  beneficial  for  the  relief  of  pain 
when  placed  on  excoriated  surfaces — as  ulcers,  burns,  etc. — and 
deserve  to  be  mentioned  for  the  treatment  of  after  pains  arising 
from  the  extraction  of  teeth.  As  orthoform  is  irritating  to  the  soft 
tissues,  occasionally  sloughing  is  observed  after  its  too  free  use  as 
a  dusting  powder.  The  orthoforms  are  now  largely  supplanted  by 
novocain. 


»Prinz:  Dental  Cosmos,  1911,  p.  91. 

*  When  camphor  and  chloral  hydrate  are  brought  together,  both  substances  will  become 
liquefied. 


LOCAL   ANESTHETICS    AND    OBTUNDENTS  323 

Anesthesin  and  Suhcutin.  Both  chemicals  are  orthoform  modi- 
fications. Anesthesin  is  insoluble  in  water,  while  its  hydrochloric 
salt  is  soluble  in  water  to  the  extent  of  1  per  cent.  The  parasul- 
phonate  of  anesthesin  is  known  as  subcutin.  Their  solutions  may- 
be boiled;  they  react  strongly  acid,  and  consequently  produce 
severe  pain  when  injected  hypodermically. 

Cycloform.  Isobutyl  para-amino-benzoate.  It  is  a  white  crystal- 
line, odorless  powder,  slightly  soluble  in  water,  but  soluble  in 
ether,  alcohol  and  olive  oil.  It  is  usually  employed  as  a  dusting 
powder  or  in  5  to  20  per  cent  ointments. 

Propcesin.  Propyl  amino-benzoate.  It  is  a  fine  white  or  color- 
less and  odorless  powder,  very  slightly  soluble  in  water,  but  soluble 
in  ether,  chloroform  and  alcohol.  It  is  used  externally  as  a  dust- 
ing power  or  in  ointments  containing  from  1  to  20  per  cent.  In- 
ternally it  is  given  in  doses  of  4  to  8  grains  (0.25-0.5  Gm.)  in 
all  painful  wounds  and  ulcers  of  the  mucous  membrane,  etc. 

Anesthetic  Mixtures. 

IJ     Orthoformii 

Amyli  aa  3  j   (4  Gm.) 

M. 

Sig. :     Dusting  powder. 

IJ     Orthoformii  3  j    (4  Gm.) 

Lanolini  3  j    (30  Gm.) 

M.  f.  unguentum. 
Sig.:      Orthoform  ointment. 

The  Chemic  Relationship  of  the  More  Important  Local 

Anesthetics. 

The  basic  chemic  formula  which  furnishes  the  nucleus  of  a  very  large  variety 
of  important  organic  medicinal  compounds  is  the  benzol  ring. 

CH 

ch/\ch 


chV/ch 

CH 

By  a  complicated  process  of  addition  and  substitution,  a  number  of  bodies 
are  produced  which,  in  their  physiologic  action  on  sensory  nerve  tissues,  re- 


324 


PHARMACO-THERAPEUTICS 


semble  cocain— that  is,  they  possess  local  anesthetic  properties.  Cocain,  dis- 
covered by  Niemann  in  1859,  is  chemically  a  methyl-benzoyl-ester  of  ecgonin, 
C„H„NO«;  it  is  closely  related  to  atropin  and  the  tropins,  or,  rather,  the 
pseudotropins.  Lossin,  in  1865,  had  demonstrated  that  by  decomposing  cocain 
the  following  products  were  formed:  Ecgonin,  benzoic  acid,  and  methyl 
alcohol. 

Ecgonin  differs  from  pseudotropin  only  by  having  a  carboxyl  group  pres- 
ent. In  1898  Willstatter  definitely  settled  the  chemic  relationship  between 
cocain  and  ecgonin  by  expressing  their  structural  formulas: 


CH, 


-CH- 


CH,- 


NCH, 

-ok- 


COCAIN. 

-CH.COOCH, 

CH.O.CO.C.H, 
-CH, 


CH,- 


ECGONIN. 
-CH CH.COOH 


CH, 


NCH,         CH.OH 

L        I 

-CH CH, 


Judging  from  these  constitutional  formulas,  it  seems  that  the  required  con- 
dition for  the  construction  of  a  local  anesthetic  rests,  a  priori,  on  a  base  with 
a  structure  analogous  to  ecgonin,  containing  a  benzoyl  and  an  alkyl  radical 
in  certain  relations.  A  synthetic  compound  which  is  expected  to  be  closely  re- 
lated in  its  physiologic  action  to  cocain  should  therefore  include  in  its  formula 
the  following  basic  groups: 

1.  An  element  of  nitrogen. 

2.  A  benzoyl  group  (the  radical  of  benzoic  acid),  substituting  the  hydrogen 
of  an  OH  group. 

3.  The  COOH  group  (acid  radical). 

As  an  early  substitute  of  cocain,  tropa-cocain  should  be  mentioned.  In  1891 
Giesel  isolated  it  from  the  coca  leaves  grown  in  Java,  and  Liebermann,  in 
1892,  and  Willstatter,  in  1896,  prepared  it  synthetically.  Chemically,  tropa- 
cocain  is  benzoyl  pseudotropin;  its  hydrochloric  salt,  CibHjjNO^.HCI,  is  less 
poisonous  than  cocain,  but  has  an  almost  equal  potency. 

Meditating  on  the  structural  formulas  of  ecgonin  and  tropin,  Merling,  in 
1896,  conceived  the  idea  that  certain  benzoyl  derivatives  which  are  closely  re- 
lated to  tropin,  like  triacetonalkamin  and  vinyldiacetonalkamin,  must  also 
possess  definite  anesthetic  properties.  On  this  supposition  he  prepared  the 
methyl  esteri  of  benzoyltriacetonalkaminocarbonic  acid.  This  compound  was 
later  designated  by  Vinzi  as  eucain  or  eucain  A,  or  alpha-eucain.  Eucain  A 
is  very  strongly  irritating  to  the  soft  tissues;  to  eliminate  this  factor,  Vinzi 
slightly  altered  the  structure  of  the  formula,  which  resulted  in  the  production 
of  eucain  B,  or  beta-eucain,  benzoylvinyldiacetonalkamin  hydrochlorid,  C^/ 
H,.0,N.HC1+HjO. 

A  year  later,  in  1897,  Einhorn  and  Heinz  showed  that  in  these  complex  de- 
rivatives of  the  benzol  ring  the  nitrogen  molecule  was  not  an  absolute  necessity 
for  the  production  of  local  anesthetic  effects;  they  found  that  almost  all  of 


*  The  combination  of  an  organic  acid  with  a  phenol  or  an  alcohol  is  known  as  an  ester. 


LOCAL    ANESTHETICS    AND    OBTUNDENTS  325 

the  alkyl  compounds  of  the  esters  of  the  amino  acids  and  oxyamino  acids 
possess  very  marked  local  anesthetic  properties.  The  first  body  built  on  this 
supposition  in  1898  by  the  above  named  chemists  is  orthoform,  the  methyl 
ester  of  paraaminometaoxybenzoic  acid  (CgH3(0H)  (NH,)  (COOCH3)).  It  was 
followed  by  its  modification,  orthoform  new,  the  methyl  ester  of  metamino- 
paraoxybenzoic  acid,  which  is  prepared  by  simple  reversion  of  the  OH  and 
the  NHj  groups.  Both  compounds  dissolve  with  difficulty  in  water;  they  have 
a  slight  acid  reaction,  and,  on  account  of  the  resultant  irritation,  are  limited 
in  their  uses.  To  further  eliminate  this  side  action  of  orthoform,  Einhorn  and 
Heinz  substituted  glycocoll  derivatives,  and,  in  1898,  introduced  a  few  com- 
pounds of  this  group  which  are  known  as  nirvanin,  holocain,  and  acoin.  These 
compounds  are  comparatively  valueless  as  anesthetics,  and,  on  account  of  their 
more  or  less  intense  irritation,  they  have  never  been  employed  to  any  appreciable 
extent. 

The  discovery  of  the  orthoform  group  stimulated  renewed  activity  for  the 
further  search  of  new  local  anesthetic  bodies.  Eitsert,  in  1901,  eliminated  the 
hydroxyl  group  from  orthoform,  and  thus  produced  anesthesin,  the  ethyl  ester 
of  paraminobenzoic  acid,  an  insoluble  compound,  which  does  not  possess  any 
advantage  over  orthoform.  In  preparing  its  p-phenolgulphonic  acid  salt,  sub- 
cutin,  a  soluble  and  less  irritating  anesthetic  is  obtained.  None  of  the  va- 
rious compounds  so  far  mentioned  have  become  meritorious  substitutes  of  co- 
cain;  they  have  never  gained  the  confidence  of  the  profession,  and  are  at  pres- 
ent largely  abandoned. 

Fourneau,  a  French  chemist,  working  under  Fischer  in  the  Chemic  Institute 
of  the  University  of  Berlin,  prepared  in  1904  a  chain  of  compounds  in  which 
he  incorporated  the  alcohol  radical  with  the  nitrogen  atom  of  the  original 
benzol  ring.  The  most  effective  of  these  compounds  is  known  as  stovain, 
dimethylaminobenzoylpentanol  hydrochlorid,  Cj^HjiNO^-HCl.  Stovain,i  being 
readily  soluble  in  water,  reacts  strongly  acid,  and  therefore  irritates  to  a  con- 
siderable extent  the  soft  tissues.  To  further  modify  this  acid  property,  Im- 
pens,  in  1905,  added  a  dimethylamino  group  to  the  second  methyl  group,  thus 
creating  a  neutral  body  known  as  alypin,  CuH^jNOj.HCl,  benzoyltetramethyl- 
diaminoethylisopropylalcohol  hydrochlorid,  which,  however,  is  still  irritating  to 
the  tissues. 

From  the  extensive  experimental  work  conducted  by  the  various  investigators 
it  becomes  very  convincing  that  the  search  for  a  local  anesthetic  which  would 
possess  all  the  good  qualities  of  cocain,  without  its  poisonous  effects  or  any 
irritating  side  action,  must  be  looked  for  in  the  salts  of  the  alkaminesters  of 
the  aminobenzoic  acid — that  is,  the  modified  orthoform  group.  Einhorn  and 
Uhlfelder  again  returned  to  anesthesin,  taking  it  as  a  base  for  their  synthetic 
research,  and,  after  producing  some  400  odd  variations,  finally,  in  1905,  suc- 
ceeded in  preparing  the  hydrochloric  salt  of  paraamidobenzoyldiethylamino- 
ethanol,  CgH,.NH2.CO,.C2H,.N(C,H,)j.HCl,  a  diethylamino  derivative  of  anes- 
thesin, which  they  termed  novocain.    Of  all  the  synthetic  substitutes  of  cocain 


*  Fourneau  translated   his  name  into   English — stove— and   from   this  word   created   the 
word  stovain. 


326  PHABMACO-THERAPEUTICS 

SO  far  offered  to  the  profession,  novocain  seems  to  answer  the  demands  better 
than  any  other  known  compound. 

In  comparing  the  structural  relationship  of  some  of  the  modern  local  anes- 
thetics, it  is  interesting  to  observe  that  the  base  of  the  orthoform  groups  and 
eugenol  resemble  each  other  closeh'.  Eugenol,  paraoxymetamethoxyallyl  ben- 
zol, C„H,jO„  or  C.HjCOH)  (0CH3).(CH,.CH:CHj)  (4:3:1),  is  the  principal 
active  constituent  of  oil  of  cloves;  it  is  also  found  in  many  other  essential 
oils.  Oil  of  cloves  enjoys  an  old  and  much  lauded  reputation  as  an  effective 
toothache  remedy,  which  it  owes  solely  to  the  presence  of  eugenol.  Eugenol, 
while  being  strongly  anesthetic,  is  also  slightly  caustic.  To  eliminate  this 
caustic  action,  the  p-aminobenzoic  acid  was  isolated,  which,  however,  proved 
wholly  inactive.  The  ethyl  ester  of  this  acid,  as  we  have  seen,  forms  anesthesin, 
and  the  hydrochlorid  of  this  diethylaminoethanol  ester  is  known  as  novocain. 
Both  anesthetics  may  be  commercially  prepared  from  the  oil  of  cloves. 

Refrigerant  Local  Anesthetics. 

Refrigerant  anesthetics  are  local  applications  which  abstract 
heat  from  the  tissues.  They  lower  the  temperature,  diminish  sen- 
sation, and  reduce  the  volume  of  the  parts  to  which  they  are  ap- 
plied. Their  continuous  application  produces  in  due  time  definite 
anesthesia.  The  application  of  freezing  agents  should  be  restricted 
to  small  areas. 

Ether;  ^ther,  U.  S.  P.,  B.  P.;  (C.Hg)^^ 

Pure  ethyl  ether  of  at  least  95  per  cent  and  a  boiling  point  of 
95°  F,,  (35°  C.)  is  essential  to  obtain  good  results.  Freezing  and 
the  subsequent  anesthesia  of  the  tissues  is  only  slowly  produced  by 
ether.  Special  apparatus  are  necessary  for  the  ready  dessemina- 
tion  of  the  ether  vapors;  those  of  Richardson  and  of  Lasser  are 
especially  adapted  for  the  teeth.  To  obtain  good  results,  the  ether 
spray  should  be  brought  in  close  contact  with  the  tissues.  The  tis- 
sues become  intensely  red  and  then  white;  the  latter  color  indi- 
cates complete  anesthesia.  The  vapors  of  ether  are  very  inflamma- 
ble; even  the  spark  from  an  electric  light  switch  has  caused  an 
explosion  of  ether  vapors  in  an  operating  room.  Ether  is  rarely 
used  at  present  for  local  anesthetic  purposes  in  dentistry. 

Ethyl  Chlorid  ;  ^thylis  Chloridum,  U.  S.  P. ;  C2H5CI ;  Anti- 

DOLORINE;   KeLENE;  NaRCOTILE. 

A  colorless,  mobile,  very  volatile  fluid,  having  an  agreeable  odor 
and  burning  taste.    On  account  of  its  extreme  volatility  it  is  best 


LOCAL   ANESTHETICS    AND   OBTUNDENTS  327 

preserved  in  hermetically  sealed  glass  or  metallic  tubes,  and  kept 
in  a  cool  place,  removed  from  light  and  fire.  It  boils  at  about 
55°  F.  (12.8°  C).  P]thyl  chlorid  produces  a  satisfactory  local 
anesthesia  by  freezing,  and  is  probably  the  best  agent  used  for 
such  vi^ork.     (See  Local  Anesthetics.) 

Methyl  Chlorid;  Methylis  Chloridum;  CH3CI. 

A  colorless,  mobile,  and  very  volatile  fluid,  having  a  rather 
agreeable  odor.  It  boils  at — 12°  F.  ( — 24.5°  C),  and  must  be 
kept  in  strong  metallic  cylinders.  The  methyl  chlorid  spray  pro- 
duces a  very  quick  and  intense  freezing  of  the  tissues,  frequently 
resulting  in  necrosis;  for  this  reason  it  is  seldom  applied  in  its 
pure  state  in  dentistry  at  present.  To  modify  the  severe  action  of 
methyl  chlorid,  it  is  mixed  with  ethyl  chlorid  in  various  propor- 
tions, and  is  known  as  coryl.  Another  mixture  of  equal  parts  of 
methyl  and  ethyl  chlorid  is  known  as  anesthile  (Bengue),  as  anestol 
(Speier)  ;  and  as  methethyl  (Henning)  ;  the  latter  mixture  con- 
tains some  chloroform. 

Local  anesthesia  by  means  of  refrigerant  agents  is  much  less 
employed  at  present  than  in  former  years.  The  general  applica- 
bility and  comparative  safety  of  local  anesthesia  by  cocain  or  its 
substitutes  have  almost  completely  superseded  the  freezing  method, 
which,  at  best,  is  a  rude  method  of  subduing  pain. 

Other  Local  Anesthetics. 

Phenol  enjoys  quite  a  reputation  as  a  local  anesthetic,  especially 
in  dental  surgery.  As  it  is  very  strongly  irritating,  and  even  caus- 
tic if  applied  in  solutions  sufficiently  concentrated  to  cause  local 
anesthesia,  it  is  prone  to  produce  phenol  (carbolic  acid)  necrosis. 
Guaiacol,  which  is  closely  related  to  phenol,  possesses  also  slightly 
anesthetic  properties;  when  injected  it  produces  necrosis.  Kava- 
kava,  a  resin  prepared  from  the  roots  of  Piper  metJiysticum,  pos- 
sesses pronounced  anesthetic  properties;  it  is  too  irritating  to  be 
used  for  injection.  Yohimbin,  an  alkaloid  of  the  yohimbe  bark, 
acts  as  an  anesthetic  if  injected  as  a  1  per  cent  solution ;  it  possesses 
pronounced  virtues  in  the  treatment  of  certain  forms  of  impo- 
tence. Quite  a  number  of  other  drugs  possess  local  anesthetic  ac- 
tion— menthol,  chloroform,  aconite,  etc. — and  are  all  more  or  less 
frequently  employed  externally  in  the  form  of  liniments,  oint- 
ments, etc.    Merely  to  complete  the  list,  a  few  more  of  the  recent 


328  PHARMACO-THERAPEUTICS 

additions  to  the  long  list  of  local  anesthetics  may  be  named — adon- 
idin,  convallamarin,  dionin,  helleborin,  peronin,  and  vanillic  acid. 
Carbonic  acid  in  the  form  of  soda  water  or  champagne  deserves  to 
be  mentioned  as  a  prompt  anesthetic  of  the  stomach  in  case  of 
nausea. 

Redard/  of  Geneva,  in  1904  introduced  the  use  of  blue  light  as 
a  local  anesthetic.  Apparently  the  anesthesia  obtained  with  this 
light  is  a  form  of  analgesia,  which  in  all  probability  is  as  much  due 
to  suggestion  as  to  the  blue  light  itself.  Since  Redard's  publica- 
tion appeared  nothing  further  of  importance  has  been  published. 
Anesthetization  by  blue  light  has  never  become  popular. 

GENERAL  ANESTHETICS. 

Anesthetics  (without  sensation),  sometimes  referred  to  as  nar- 
cotics (loss  of  sensation  and  consciousness),  are,  in  a  restricted 
sense  of  the  term,  substances  which,  when  inhaled  into  the  lungs, 
act  on  the  central  nervous  system  and  cause  an  artificial  depriva- 
tion of  all  sensation.  The  principal  anesthetics  employed  for 
dental  purposes  are  nitrous  oxid,  ethyl  bromid,  ethyl  chlorid,  ether, 
chloroform,  etc.,  and  various  mixtures  of  these  and  other  sub- 
stances. 

The  discovery  of  general  anesthesia  is  so  closely  interwoven  with 
the  evolution  of  dentistry  in  the  United  States  that  it  is  impossible 
to  mention  the  one  without  referring  to  the  other.  The  blessings 
of  anesthesia  to  suffering  humanity  can  not  be  overestimated,  and 
what  Liecky  has  written  is  certainly  true:  "It  is  probable  that 
the  American  inventor  of  the  first  anesthetic  has  done  more  for  the 
general  happiness  of  mankind  than  all  the  moral  philosophers." 
It  is  not  our  intention  to  present  at  this  moment  a  detailed  account 
of  this  most  important  occurrence,  and  we  wish  merely  to  refer  to 
a  few  incidents  which  may  facilitate  a  clearer  comprehension  of 
the  matter  under  consideration.^ 

According  to  more  recent  investigations,  it  is  probably  a  set- 
tled fact  that  nitrous  oxid  was  discovered  by  Joseph  Priestly  in 
1772,  who  gave  it  the  name  "  dephlogisticated  nitrous  air."^     In 


»Redard:  Ash's  Quarterly  Circular,  1904,  p.   30S. 

*  Excellent  accounts  of  the  much  discussed  subject  of  the  discovery  of  anesthesia  are 
found  in  the  following  works:  Nevius:  Discovery  of  Modern  Anesthesia,  1894;  McManus: 
Notes  on  the  History  of  Anesthesia  and  the  Wells  Memorial  Celebration,  1896;  Hewitt: 
Anesthetics  and  Their  Administration,  1907.  The  many  works  on  general  anesthesia  usually 
furnish  more  or  less  extended  records  on  this  subject. 


GENERAL   ANESTHETICS  329 

the  succeeding  years  he  referred  to  the  substance  quite  frequently, 
and  it  soon  aroused  general  interest,  becoming  an  important  sub- 
ject for  discussion  in  the  learned  societies.  The  big  lecture  hall  of 
the  Royal  Institute  of  England  was  frequently  the  scene  of  public 
demonstrations  of  the  physiologic  effects  of  the  "  dephlogisticated 
nitrous  air,"  at  which  Count  Rumford,  Davy,  and  other  notables 
of  the  time  were  usually  present.  A  peculiar  accident  which  oc- 
curred at  one  of  these  meetings  gave  inspiration  to  Gilray  for  his 
caricature,  which  at  the  time  very  much  amused  the  learned  men 
of  England.^ 

The  preparation  of  nitrous  oxid  from  ammonium  nitrate  is  to  be 
credited  to  the  celebrated  astronomer  Laplace.  Sir  Humphrey  Davy 
conducted  careful  investigations  of  this  much  discussed  substance, 
and  soon  became  acquainted  with  the  exhilarating  influence  which 
it  exercised  on  himself  and  on  some  of  his  friends.  His  experiments 
were  published  in  1800.^  It  is  interesting  to  observe  that  Davy 
made  various  allusions  to  the  physiologic  action  of  this  gas.  He 
states  that  '  *  the  effects  of  nitrous  oxid  on  different  individuals  and 
on  the  same  individual  at  different  times  proved  that  its  powers 
are  capable  of  being  modified,  both  by  the  peculiar  conditions  of  or- 
gans and  by  the  state  of  the  general  feeling."  He  recognized  its 
possible  use  as  an  anesthetic,  for  he  says  that  "it  may  probably  be 
used  to  advantage  during  surgical  operations  in  which  no  great  ef- 
fusion of  blood  takes  place,"  a  prophecy  which  required  nearly  half 
a  century  to  become  true.  But  not  alone  was  its  anesthetic  effect 
recognized  by  him,  but  he  also  pointed  out  its  comparatively  safe 
administration  by  saying:  "Modifications  of  the  powers  of  nitrous 
oxid  by  mixtures  of  gas  with  oxygen  or  common  air  will  probably 
enable  the  most  delicately  sensible  to  respire  it  without  danger,  and 
even  with  pleasurable  effects. ' ' 

Demonstrations  of  the  exhilarating  effects  of  nitrous  oxid  were 
a  prolific  source  of  public  entertainments  in  England  in  the  years 

»  Cohen:  Das  Lachgas,  1907. 

'Davy:  Researches  on  Nitrous  Oxid,  1800. 

"Not  in  the  ideal  dreams  of  wild  desire 

Have  I  beheld  a  rapture-waking  form: 
My  bosom  burns  with  unhallowed  fire, 

Yet  is  my  cheek  with  rosy  blushes  warm; 
Yet  are  my  eyes  with  sparkling  luster  fill'd; 

Yet  is  my  mouth  replete  with  murmuring  sound; 
Yet  are  my  limbs  with  inward  transports  fill'd, 

And  clad  with  newborn  mightiness  around." 


330  PHARMACO-THERAPEUTICS 

following  its  discovery,  and  in  due  time  found  their  way  into  the 
United  States.  It  was  at  one  of  these  demonstrations  that  the  con- 
ception of  its  utilization  for  the  purpose  of  producing  insensibility 
to  pain  was  conceived  by  a  dentist.  This  conception  and  its  suc- 
cessful application  marked  the  birthday  of  anesthesia.  The  inci- 
dent is  recorded  as  follows  :* 

"On  the  evening  of  December  10,  1844,  Dr.  Horace  Wells,  a  practicing 
dentist  of  Hartford,  Conn.,  attended  in  that  city  a  chemical  lecture  by  Mr. 
G.  Q.  Colton,  during  or  after  which  the  lecturer  administered  to  Mr.  Samuel 
A.  Cooley  and  others  the  nitrous  oxid  gas.  Mr.  Cooley,  on  being  brought 
under  its  influence,  became  unusually  excited,  and,  during  his  consequent 
activity,  sustained  severe  bruises,  of  which  fact  he  was  unconscious  until 
after  recovery  from  the  effects  of  the  gas.  His  asseverations  of  want  of 
knowledge  of  any  pain  while  in  the  unconscious  condition  took  strong  hold 
on  the  mind  of  Dr.  Wells,  and  he  immediately  expressed  his  belief  that 
teeth  could  be  painlessly  extracted  during  the  inhalation  of  this  agent.  So 
strongly  was  he  thus  impressed  that  the  next  day  he  requested  Mr.  Colton 
to  provide  some  of  the  gas  for  him,  which  he  took  himself,  holding  the  bag 
in  his  lap,  and  while  under  its  influence  underwent  the  extraction  of  a  molar 
tooth  at  the  hands  of  Dr.  John  M.  Riggs,  a  fellow-dentist  of  Hartford. 
Upon  his  recovery  Wells  exclaimed  in  high  glee,  'A  new  era  in  tooth  pull- 
ing! '  The  exclamation  was  prophetic.  So  elated  were  Drs.  Wells  and  Riggs 
at  the  success  of  their  experiment  that  they  immediately  turned  their  at- 
tention to  the  extraction  of  teeth  by  the  aid  of  this  agent,  and  continued 
to  devote  themselves,  in  conjunction,  to  this  subject  for  several  weeks  al- 
most exclusively.  Dr.  Wells  used  the  gas  freely  during  the  whole  time  of 
his  dental  practice,  and  Dr.  Riggs  employed  it  constantly  *as  people  de- 
manded it,  which  they  ordinarily  did,'  until  1847,  when  he  began  to  employ 
chloroform  in  its  stead.  Wells,  however,  was  not  content  to  demonstrate 
the  availability  of  nitrous  oxid  as  an  anesthetic  in  dentistry  alone,  but 
carried  it  into  general  surgery.  The  first  recorded  case  of  this  character 
occurred  on  August  17,  1847,  being  the  extirpation  of  a  large  scirrhous 
growth  by  E.  E.  Marcy,  M.D.,  then  of  Hartford.  The  case  is  reported  at 
length  in  the  Boston  Medical  and  Surgical  Journal,  September  1,  1847. 
The  gas  was  administered  by  Dr.  Wells,  and  its  operation  was  entirely  satis- 
factory. The  second  case  was  amputation  of  the  thigh,  occurring  January 
1,  1848;  the  operator.  Dr.  P.  W,  Ellsworth,  and  the  gas  given  by  Dr.  Wells. 
This  case  is  also  reported  in  the  above  periodical.  Vol.  XXVII,  p.  498.  The 
last  we  shall  mention  was  the  removal  of  a  fatty  tumor  from  the  shoulder 
at  Hartford,  January  4,  1848;  S.  B.  Beresford,  M.D.,  the  operator,  and  the 
gas  given,  as  before,  by  Horace  Wells.  This  was  only  twenty  days  before 
Wells'  death.  Almost  immediately  upon  Wells'  discovery  the  use  of  the 
gas  became  quite  general  with  the  Hartford  dentists.     John  B.  Terry   (after- 

*  A  History  of  Dental  and  Oral  Science  in  America,  prepared  under  the  direction  of 
the  American  Academy  of  Dental   Science,   1876. 


GENERAL   ANESTHETICS    '  331 

ward  Dr.  Wells'  associate  in  practice),  John  Braddock,  and  E.  E.  Crowfoot, 
all  dentists  of  that  city,  used  the  agent  between  the  time  when  Wells 
brought  it  to  notice  and  September  30,  1846,  a  date  which  will  be  presently 
noticed  in  connection  with  the  subject  of  ether.  A  short  time  after  his  dis- 
covery, Dr.  Wells  visited  Boston  in  order  to  bring  it  before  the  medical 
men  of  that  city.  Calling  on  Professor  Warren,  of  the  Harvard  Medical 
College,  he  communicated  the  facts  to  him,  and  was  referred  to  the  students 
for  examination,  before  whom  he  administered  the  gas  to  a  patient  who 
desired  a  tooth  drawn;  but,  probably  from  the  bag  containing  the  agent 
being  withdrawn  too  soon,  the  patient  made  some  noise  during  the  opera- 
tion, although  he  afterward  asserted  that  he  had  not  felt  pain.  From  this 
unfortunate  circumstance  the  majority  present  thought  the  experiment  a 
failure,  though  many  considered  that  complete  anesthesia  had  been  pro- 
duced, and  afterwards  made  oath  or  published  statements  to  that  effect.  Of 
these  may  be  mentioned  Wm.  M.  Cornell,  Mason  M.  Miles,  and  C.  A.  Taft. 
While  in  Boston  at  this  time,  and  previous  to  his  experiment  at  the  Harvard 
school.  Dr.  Wells  called  on  Dr.  Charles  T.  Jackson  and  Dr.  Wm.  T.  G. 
Morton,  the  latter  an  old  pupil  and  partner  of  his,  and  communicated  his 
discovery  to  them.  This,  it  will  be  remembered,  occurred  in  December, 
1844.  These  gentlemen  'expressed  themselves  in  the  disbelief  that  surgical 
operations  could  be  performed  without  pain,  both  admitting  that  the  modus 
operandi  was  entirely  new  to  them.'  The  fact  of  this  visit,  at  the  date 
and  for  the  purpose  alleged,  is  admitted  by  Morton  in  his  subsequent 
memoir  to  the  French  Academy  of  Arts  and  Sciences  on  the  subject  of  the 
discovery  of  the  anesthetic  effects  of  sulphuric  ether.  After  the  discovery 
was  made.  Wells  had  frequent  interviews  with  Morton  on  the  subject,  and 
the  latter  requested  instructions  in  the  preparation  of  the  gas,  as  he  wished 
to  try  it  in  Boston.  Probably  aware  of  the  danger,  to  a  nonchemist,  of 
preparing  the  nitric  oxid  in  place  of  the  nitrous  oxid.  Wells  advised  Morton 
to  go  to  Dr.  Jackson  in  Boston,  who  was  a  chemist  and  could  prepare  th»» 
gas  properly.    This  fact  is  susceptible  of  abundant  proof. ' ' 

Ether  was  discovered  in  the  middle  of  the  sixteenth  century  by 
Cordus,  but  it  remained  for  two  American  physicians  and  two 
American  dentists  to  introduce  it  as  a  general  anesthetic  between 
1842  and  1846.  Crawford  W.  Long,  M.  D. ;  Charles  T.  Jackson, 
M.  D.,  and  the  dentists,  Horace  Wells  and  William  T.  G.  Morton, 
are  the  four  claimants  for  this  honor.  Long  used  ether  as  a  gen- 
eral anesthetic  as  early  as  1842,  but,  living  in  a  little,  obscure 
country  place  in  Georgia,  and  not  having  made  public  his  ex- 
periences with  this  anesthetic,  the  discovery  remained  unknown  to 
the  world  at  large.  The  first  publication  by  Long  regarding  the 
use  of  ether  appeared  in  December,  1847.*  Without  knowledge  of 


»  Long:  An  Account  of  the  First  Use  of  Sulphuric  Kther  by  Inhalation  as  an  Anesthetic 
in  Surgical  Operations,   Southern  Medical  and  Surgical  Journal,   1849. 


332  PHARMACO-THERAPEUTICS 

Long's  discovery,  Morton  introduced  ether  in  Boston  in  1846  as 
"Letheon" — ether  mixed  with  essential  oils  to  disguise  its  odor. 
The  ether  was  prepared  for  him  by  Jackson.  Wells,  however, 
who  was  experimenting  with  nitrous  oxid  and  other  anesthetic  sub- 
stances two  years  prior  to  Morton's  discovery,  administered  ether 
as  an  anesthetic  in  1845.  Wells  received  the  suggestion  of  using 
ether  for  such  purposes  from  E.  E.  Marcy,  M.  D.,  of  Hartford, 
Conn.,  in  1844.  It  is  not  our  intention  to  make  an  attempt  to 
settle  the  rights  of  priority  regarding  the  introduction  of  ether  as 
a  general  anesthetic;  volumes  have  been  written  about  the  con- 
troversy between  the  various  claimants.  Let  it  suffice  to  say  that 
the  above-named  gentlemen  shared  a  more  or  less  equal  right  in 
this  great  discovery. 

Chloroform  was  discovered  at  about  the  same  time  (1831-32) 
by  Samuel  Guthrie,  of  Sackett's  Harbor,  N.  Y. ;  by  Liebig,  of  Ger- 
many, and  by  Soubeiran,  of  France.  It  was  introduced  as  a  gen- 
eral anesthetic  by  Simpson,  who  in  1847  published  a  lengthy  re- 
port concerning  its  superiority  over  ether  as  observed  by  him  in 
the  clinics  of  Edinburgh  University. 

Ethyl  chlorid  was  discovered  in  1759  by  Bouelle.  In  1848  it 
was  introduced  as  a  general  anesthetic  by  Heyfelder.  The  high 
price  of  ethyl  chlorid  and  the  difficulty  of  obtaining  a  pure  product 
prevented  its  ready  adoption  as  an  anesthetic.  In  1867  Rotten- 
stein  called  attention  to  the  use  of  ethyl  chlorid  as  a  refrigerant 
agent  for  local  anesthetic  purposes,  and  in  1889  Rhein  suggested 
methyl  chlorid  for  the  same  purpose.  In  1891  ethyl  chlorid  was 
reintroduced  as  a  refrigerant  agent  by  Redard,  and  in  1895 
Carlson  observed  two  cases  of  general  anesthesia  resulting  from 
inhaling  its  vapors  when  employed  locally  in  the  mouth.  Thiesing, 
in  1896,  again  experimented  with  this  agent  in  regard  to  its  gen- 
eral anesthetic  properties,  and  in  the  same  year  Lotheisen,  Lud- 
wig,  and  Fischer,  followed  in  short  succession  by  Billeter,  Ruegg, 
Respinger,  Seitz,  Brodtbeck,  and  others,  introduced  it  again  in 
general  and  dental  surgery.  Ethyl  chlorid  forms  the  base  of 
many  mixtures  which  are  used  as  local  refrigerants  and  general 
anesthetics,  of  which  somnoform,  introduced  by  Rolland  in  1902, 
is  probably  the  best  known  type. 

Nitrous  Oxid;  Nitrogenii  Monoxidum,  U.  S.  P.;  N^O. 
Synonyms. — Nitrogen    monoxid,    nitrogen    protoxid,    laughing 


GENERAL   ANESTHETICS 


333 


gas,  dephlogisticated  nitrous  air;  protoxyde    d 'azote,    F, ;    Stick- 
stoffoxydul,  Lachgas,  G. 

Source  and  Character. — Nitrous  oxid  was  first  obtained  by 
Priestly,  in  1772,  by  the  action  of  nitric  acid  on  moist  iron  filings. 
Laplace  and,  later,  Berthollet  prepared  the  gas  from  ammonium 
nitrate,  and  Deiman  and  Troostweijk,  in  1773,  determined  its  com- 
position. Davy,  in  1800,  observed  its  exhilarating  effects  and 
referred  to  its  probable  use  as  a  general  anesthetic.  Nitrous  oxid 
is  usually  prepared  from  ammonium  nitrate,  which  should  be  free 
from  chlorids,  by  gradual  decomposition  by  heat.  At  present  a 
mixture  of  dried  sodium  or  potassium  nitrate  and  dried  ammonium 


HaSO 


Apparatus  for  making  nitrous  oxid.  A  Lennox  porcelain-lined  iron  retort  is  connected 
with  a  series  of  wash  bottles,  ready  for  use.  The  last  wash  bottle  is  connected  with  the 
storage  tank. 


sulphate  is  also  employed;  it  is  said  that  the  preparation  of  the 
gas  from  this  mixture  is  free  from  danger.  In  preparing  the  gas 
the  dry  ammonium  nitrate  is  placed  in  a  spacious  glass  or  porce- 
lain-lined iron  retort,  connected  with  a  series  of  wash  bottles  and 
the  storage  tank  of  a  gasometer,  and  heat  is  applied.  The  am- 
monium nitrate  decomposes  at  about  392°  F.  (200°  C.)  ;  the  heat 
should  never  be  carried  above  465°F.  (240°  C),  to  prevent  the 
formation  of  poisonous  nitric  oxid  and  nitrogen.  The  decomposi- 
tion of  ammonium  nitrate  into  water  and  nitrous  oxid  takes  place 
according  to  the  equation: 


334  PHARMACO-THERAPEUTICS 

NH,N03=2H20+N20. 

The  wash  bottles  contain  respectively  solutions  of  ferrous  sul- 
phate, sodium  hydroxid,  and  a  strong  solution  of  sulphuric  acid 
for  the  purpose  of  removing  impurities — chlorin,  nitric  oxid,  am- 
monia, etc. — from  the  gas  and  to  dry  it.  The  removal  of  the  am- 
monia compounds  is  especially  desirable  as  these  substances  are 
principally  responsible  for  the  cyanosis  and  other  ill  effects  on 
the  patient.  One  pound  of  ammonium  nitrate  will  approximately 
yield  thirty-two  gallons  of  nitrous  oxid  (500  grams  yield  about 
140  liters). 

Nitrous  oxid  is  a  colorless,  elastic  gas,  having  a  very  slightly 
agreeable  odor  and  a  sweetish  taste.  It  has  a  specific  gravity  of 
1.6  (Dalton),  and  a  gallon  of  it  weighs  approximately  14  ounce 
(1  liter  weighs  about  2  grams).  At  30°F.  (0°  C.)  and  under  a 
pressure  of  50  atmospheres  it  is  liquefied  into  a  stable,  colorless, 
very  mobile  fluid;  at  —148°  F.  (—100°  C.)  it  solidifies  into  color- 
less crystals.  Liquefied  nitrous  oxid  boils  at  about  — 126°  F. 
( — 88°  C).  The  gas  is  fairly  soluble  in  water,  alcohol,  ether,  and 
volatile  and  fixed  oils.  Nitrous  oxid  supports  combustion  in  the 
presence  of  'oxygen,  but  it  does  not  support  life.  Unless  nitrous 
oxid  is  used  in  large  quantities,  at  present  its  preparation  is 
usually  not  undertaken  by  the  general  practitioner  in  his  office. 
It  is  now  usually  obtained  from  the  dental  depots  in  liquid  form, 
stored  in  steel  cylinders,  which  contain  respectively  100,  250,  450, 
or  1,000  gallons.  These  cylinders  are  painted  black  to  differentiate 
them  from  the  cylinders  containing  compressed  oxygen,  which  are 
painted  red. 

Physiologic  Action  of  Nitrous  Oxid. 

As  stated,  nitrous  oxid  supports  combustion  in  the  presence  of 
air,  but  it  does  not  support  life.  Plants  will  not  grow  in  an  atmos- 
phere of  pure  nitrous  oxid,  nor  will  seed  germinate.  NgO  is  an 
inorganic  compound;  it  will  not  decompose  in  the  lungs,  and  will 
not  enter  into  chemic  combination  with  the  blood,  but  is  readily 
mechanically  absorbed  by  the  latter  without  entering  into  a  true 
solution  and  without  affecting  its  hemoglobin.  When  the  further 
supply  of  N2O  is  discontinued,  the  inner  pressure  of  the  gas  in 
the  lungs  is  released,  and  the  blood  quickly  gives  up  N2O,  replac- 
ing it  with  normal  air.    When  an  animal  is  exposed  to  an  atmos- 


GENERAL   ANESTHETICS  335 

phere  of  nitrous  oxid,  the  metabolism  of  the  tissue  cells  is  in- 
hibited in  exactly  the  same  manner  as  by  the  presence  of  any 
other  indifferent  gas  which  may  have  taken  the  place  of  oxygen, 
and  the  animal  finally  dies  from  asphyxiation.  The  asphyxiating 
factor  has  been  denied  by  Luke^  and  by  others.  Wood^  has,  how- 
ever, clearly  demonstrated  that  the  action  of  NjO  on  the  blood  is 
largely  of  an  asphyxiating  character,  as  even  so  slight  an  admix- 
ture as  3  parts  of  oxygen  will  delay  anesthesia  to  quite  an  extent. 
Nitrous  oxid  apparently  exercises  some  definite  influence  on  the 
central  nervous  system,  especially  the  centers  of  respiration,  and 
to  a  less  extent  on  those  of  the  circulation.  The  depression  of  the 
respiratory  centers  is  the  more  pronounced  factor.  Death  from 
NjO  poisoning  results  from  an  inhibition  of  the  functions  of  these 
centers,  combined  with  asphyxiation.  The  various  functions  of 
the  organism  under  NgO  narcosis  are  impaired  in  the  same  routine 
order  as  results  from  any  other  general  anesthetic — the  cerebrum, 
the  cerebellum,  the  medulla  oblongata,  and  finally  the  ganglia  in 
the  heart.  The  early  manifestation  of  cyanosis  indicates  the  want 
of  oxygen  and  the  irritation  of  the  respiratory  centers  in  the 
medulla,  which  is  caused  by  the  accumulated  CO2.  It  is  further 
stated  that  NgO  produces  irritation  of  the  nerve  centers  controlling 
the  genito-urinary  apparatus.  The  high  pressure  which  is  in- 
duced by  nitrous  oxid  anesthesia  is  said  to  be  dangerous  in  feeble, 
elderly  people,  but  so  far  no  proof  has  been  brought  forward  to 
substantiate  such  statement. 

Administration  of  Nitrous  Oxid. 

Before  starting  anesthetization  the  anesthetist  should  comply  in 
all  cases  with  a  fixed  set  of  rules.  A  third  person,  preferably  a 
woman,  should  always  be  present  when  a  general  anesthetic  is 
given,  and  should  remain  in  the  room  until  the  patient  has  recov- 
ered full  consciousness.  The  patient  is  seated  in  a  rigidly  ad- 
justed low  dental  chair,  or  in  an  easy  chair  with  a  high  back.  The 
patient  assumes  an  easy  position,  and  the  head  is  placed  so  as  to 
be  in  the  same  long  axis  with  the  spinal  column.  His  clothing 
must  be  loosened,  especially  about  the  neck  and  the  waist,  to  in- 
sure free  and  easy  breathing.     The  mouth  is  inspected  for  re- 

»Luke:  Guide  to  Anesthetics,  1906. 
'Wood:  Dental  Cosmos,  1893. 


336 


PHARMACO-THERAPEUTICS 


movable  dentures,  chewing  gum,  tobacco,  etc.,  and  a  suitable  mouth 
prop  is  now  selected.  Various  sizes  and  shapes  of  props  are  avail- 
able; they  are  made  of  cork,  wood,  soft  rubber,  etc.,  and  these  are 
preferable  to  metallic  props.  Props  made  of  soft  pine  wood, 
which  are  discarded  after  being  used  but  once,  are  at  present  in 


Fig.  55. 
Soft  wood  mouth  props. 

favor  with  professional  anesthetists.  Hinged  metallic  props,  work- 
ing on  the  principle  of  a  mouth  gag,  are  sometimes  of  service, 
especially  when  teeth  on  both  sides  of  the  jaws  are  to  be  removed. 
The  Lawrenz  prop  is  especially  serviceable  for  such  purposes. 
The  prop  should  always  be  secured  with  a  stout  cord  to  prevent 


Fig.  56. 

Semi-solid  rubber  bite  blocks. 


swallowing  in  case  of  accident.  The  anesthetic  apparatus,  especial- 
ly the  valves  and  other  necessary  requisities  needed  for  the  opera- 
tion, must  be  in  perfect  working  order.  Sufficient  gas  should  al- 
ways be  on  hand  to  complete  the  operation.  The  gas  is  turned 
on,  and  a  little  is  passed  through  the  bags  and  tubes  to  expel  the 
air.    After  having  put  the  mouth  prop  in  position,  the  face  hood 


GENERAL   ANESTHETICS  337 

or  inhaler  is  carefully  adjusted.  A  few  breaths  of  air  are  now 
admitted,  and  then  the  gas  is  allowed  to  be  freely  inhaled.  The 
amount  of  nitrous  oxid  necessary  for  a  single  administration  varies ; 
an  average  of  five  to  twelve  gallons  are  needed  for  a  complete 
anesthetization,  although  sometimes  very  much  larger  quantities 
are  required.  Complete  anesthesia  manifests  itself  by  deep  and 
stertorous  breathing  and  by  pronounced  cyanosis  of  the  lips. 
Chronic  muscular  spasms  of  the  limbs — jactitation — are  often  ob- 
served.    The  pupils  are  dilated,  and  the  conjunctival  reflexes  are 


Fig.  57. 
Lawrenz  Adjustable  Mouth  Prop. 

abolished;  the  eye  balls  are  often  turned  upward  and  then  become 
fixed.  The  pulse  is  full  and  bounding.  The  average  anesthesia 
lasts  about  forty-five  seconds,  and  the  patient  usually  recovers 
very  quickly.  The  after  effects  of  nitrous  oxid  are  very  slight; 
occasionally  vertigo,  slight  nausea,  and  a  mild  form  of  headache 
are  experienced.  The  various  apparatus  used  for  the  administra- 
tion of  nitrous  oxid  differ  greatly.  The  operator  who  prefers  to 
make  his  own  gas,  stores  it  in  a  gasometer,  holding  a  hundred  or 


338 


PHARMACO-THERAPEUTICS 


more  gallons,  while,  when  liquefied  N2O  is  used,  the  smaller 
gasometer,  gauged  to  ten-gallon  capacity,  is  usually  employed. 
The  inner  construction  of  the  gasometer  is  readily  understood  by 
examining  Fig.  59.  The  bell  or  gas  tank  must  be  accurately 
balanced  so  as  to  give  an  even  pressure  to  the  gas.  Most  of  the 
modern  apparatus  for  N^O  anesthesia  have  discarded  the  tank; 


Fig.  58. 
Nitrous  oxid  gasometer. 


they  carry  the  soft  rubber  bag  as  a  pressure  chamber  for  the  liber- 
ated gas.  From  the  bag  the  gas  passes  directly  into  the  inhaler, 
or,  if  it  is  administered  in  conjunction  with  oxygen,  through  a 
mixing  chamber.  The  modern  gas  tanks  are  usually  of  a  port- 
able nature,  and  the  many  different  makes  leave  a  wide  choice  for 
suitable   selection   of   the   proper   apparatus.     In   England   the 


GENERAL   ANESTHETICS 


339 


Hewitt  outfit  and  the  Lennox-Coleman  combination  outfit  are 
preferred  by  the  profession.  In  purchasing  an  English  outfit  it 
should  be  remembered  that  the  English  gas  cylinders  do  not  fit 
the  domestic  yoke  connection,  and  that  they  can  not  be  refilled  in 


TO  0»&     C'LINOeR 


Fig.  59. 
Nitrous  oxid  gasometer.     Sectional  view. 


the  United  States.  Most  English  apparatus  have  the  bag  directly 
connected  with  the  face  piece,  except  in  the  Lennox-Coleman-Pat- 
terson  types;  in  the  latter  combination  the  bag  is  attached  mid- 
way between  the  cylinders  and  the  face  piece.    Modern  American 


340 


PHARMACO-THERAPEUTICS 


Fig.  60. 

Universal  gas  stand.     A  combination  of  nitrous  oxid  and  oxygen  cylinders,  gas  bags,  gauge 
plate  and  mixing  chamber. 


GENEBAL   ANESTHETICS 


341 


gas  stands  have  the  bag  fastened  to  the  upright  of  the  stand,  or 
complete  portable  apparatus,  arranged  in  convenient  surgeon's 
bags,  may  now  be  obtained.  It  is  quite  unnecessary,  for  our  pres- 
ent consideration,  to  enter  into  a  detailed  description  of  the  work- 
ing methods  of  the  various  apparatus.  A  clear  conception  of  their 
construction  is  readily  obtained  by  examining  the  accompanying 
illustrations  of  the  more  generally  used  outfits. 

The  gas  is  conveyed  to  the  respiratory  apparatus  by  various 


Fig.  61. 
Surgeon's  portable  nitrous  oxid  apparatus. 

forms  of  inhalers,  known  as  a  face  piece  when  covering  the 
mouth  and  the  nose,  as  a  mouth  piece  when  inserted  between  the 
lips,  and  as  a  nasal  inhaler  when  held  before  the  nose  or  inserted 
into  the  nostrils.  Again,  it  is  a  matter  of  choice  of  the  operator 
which  inhaler  is  best  suited  for  his  purpose.  The  ordinary  face 
piece  is  usually  made  of  soft  rubber,  with  a  plain  rim  or  an  in- 
flatable cushion.  Recently  celluloid  face  hoods,  supplied  with  an 
inflatable  rim,  have  become  great  favorites.  The  Ash  or  the  S.  S. 
White  celluloid  hood  and  the  Strangways  aseptic  inhaler  are  ex- 


342 


PHARMACO-THERAPEUTICS 


cellent  types  of  this  important  adjunct  to  the  NgO  apparatus.  Of 
the  many  nose  inhalers  the  Teter  and  Coleman  types  answer  the 
purpose  well;  the  Coleman  improved  nasal  inhaler  is  principally 
employed  in  England.  The  Thomas  or  the  Simplex  inhaler  are 
good  types  of  mouth  pieces,  and  can  be  recommended  to  those  who 
prefer  this  method  of  administering  gas. 

Prolonged  anesthesia  by  means  of  a  mixture  of  nitrous  oxid  and 
oxygen  has  been  introduced  within  recent  years  for  the  purpose 
of  increasing  the  anesthetic  period  of  pure  nitrous  oxid.    Bert,  in 


Fig.   62. 
The  S.  S.  White  nitrous  oxid  and  oxygen  apparatus  with  large  cylinders. 

1878,  suggested  a  method  of  increasing  the  length  of  anesthesia 
by  administering  N^O  under  pressure.  Owing  to  the  cumbersome 
apparatus  required,  it  was  never  put  to  practical  use.  Later  he 
experimented  with  a  mixture  of  80  per  cent  of  nitrous  oxid  and 
20  per  cent  of  oxygen,  and  reported  that  complete  anesthetization 
could  be  readily  accomplished  by  this  mixture.  Bert's  suggestion 
was  followed  by  Martin,  Hillischer,  Witzel,  Wood,  Hewitt,  and 
others.     Hewitt  finally  devised  a  perfect  working  apparatus,  and 


GENERAL   ANESTHETICS 


343 


his  method,  with  slight  modifications,  is  the  one  which  is  uni- 
versally employed  at  present.  In  the  beginning  of  the  narcosis 
pure  N2O  is  preferably  administered,  and  only  after  full  anestheti- 
5^ation  is  obtained  oxygen  is  added  for  continuing  the  anesthesia. 


Fig.  63 


Coleman's  nasal  inhaler,  connected.  A,  nose  piece  disconnected;  B,  nose  piece  secured 
to  the  metal  connections  and  rubber  conveying  pipes;  C,  sliding  clamp;  D,  stopcock;  Ei 
mouth  cover;  F,  gas  bag;  G,  rubber  tubing  leading  to  the  union  on  the  gas  cylinders. 


During  the  administration  of  a  mixture  of  nitrous  oxid  and 
oxygen  the  pulse  is  usually  slightly  quicker  than  it  was  immedi- 
ately before  the  anesthetic  was  given,  and  it  remains  at  this  rate 
during  the  entire  narcosis.  The  eyes  are  in  most  cases  closed ;  by 
raising  the  eyelid  after  complete  anesthetization  it  will  be  noticed 
that  the  conjunctival  reflexes  are  abolished.  The  pupils  are 
usually  of  normal  size,  or  they  may  become  slightly  dilated.  The 
anesthetized  patient  should  present  the  picture  of  one  being  asleep. 


344 


PHARMACO-THERAPEUTICS 


Fig.  64. 

Tcter   combination   gas  stand.      For   the   administration   of  nitrous   oxid   and    oxygen,   and 

provided  with  chloroform  or  ether  attachment. 


GENERAL   ANESTHETICS 


345 


characterized  by  "a  softly  snoring  breathing,  a  good  pulse,  a  color 
as  near  the  normal  as  possible,  an  insensitive  ocular  conjunctiva, 
relaxed  eyelids,  a  fixed  condition  of  the  globes,  and  the  absence 
of  muscular  rigidity  in  the  extremities.  Sometimes,  and  espe- 
cially after  a  phase  of  rapid  breathing,  or  when  a  good  deal  of 
oxygen  has  been  given,  the  respiration  may  come  almost  or  com- 
pletely to  a  standstill  without  there  being  the  slightest  need  for 


Fig.  65. 

Nitrous  oxid  inhaler,  with  celluloid  hood. 


alarm.  The  apneic  state  is  associated  with  a  good  pulse  and 
color,  and  will  quickly  pass  off  when  the  proportion  of  oxygen 
is  reduced."     (Hewitt.)^ 

It  is  quite  difficult  to  state  the  exact  amount  of  oxygen  which  can 
be  safely  mixed  with  nitrous  oxid  without  disturbing  the  complete 
narcosis;  the  individuality  of  the  patient  is  the  correct  guide.  An 


*  Hewitt:  The  Administration  of  Nitrous  Oxid  and  Oxygen  for  Dental  Operations,  1897. 


346 


PHARMACO-THERAPEUTICS 


Fig.  66. 

The  S.  S.  White  nasal  inhaler. 


Fig.  67. 
Simplex  inhaler.      Sectional  view. 


GENERAL   ANESTHETICS  347 

average  of  5  to  9  per  cent  of  oxj'^gen  is  found  sufficient  for  carrying 
on  a  prolonged  anesthetization  for  an  hour  or  more.  Disagreeable 
side  or  after  effects  are  rarely  met  in  this  mixed  form  of  anesthesia, 
and,  relatively  speaking,  the  NjO+O  mixture  is  by  far  the  safest 
of  all  known  anesthetics. 


i 

4 

^ 

Fig.  68. 
The  Gwathmey  gas  oxygen  apparatus. 


Chloroform;  Chloroform,   U.   S.   P.,  B.  P.;  CHCI3;  Trichloro- 

METHAN;    ChLOROFORME,    F.  ;    CHLOROFORM,    G. 

Source  and  Character. — Chloroform  is  a  liquid,  consisting  of 
99  per  cent  by  weight  of  absolute  chloroform  and  1  per  cent  of 


348  PHARMACO-THERAPEUTICS 

alcohol.  It  should  be  kept  in  dark-colored  bottles  and  in  a  cool, 
dark  place.  At  present  it  is  usually  prepared  by  distilling  a  mix- 
ture of  chlorinated  lime  and  water  with  alcohol  or  aceton.  It  is  a 
heavy,  clear,  mobile,  and  diffusible  liquid,  having  a  characteristic, 
ethereal  odor  and  a  burning  taste.  It  has  a  specific  gravity  of 
1.475,  and  is  soluble  in  all  proportions  in  alcohol,  ether,  petroleum, 
benzin,  and  in  fixed  and  volatile  oils.  When  agitated  with  water, 
it  is  soluble  in  about  200  parts  of  the  latter.  Chloroform  is  readily 
volatilized,  and  boils  at  140°  F.  (66°  C).  It  is  not  inflammable, 
but  its  vapors  burn  with  a  green  flame. 
Average  Dose. — 5  minims  (0.3  C.c). 

Ether;  JEther,  U.  S.  P.,  B.  P.;   (03115)20 ;  Sulphuric  Ether; 
Ether  Sulphurique,  F.  ;  ScH^vEFELATHER,  G-. 

Source  and  Character. — It  is  a  liquid,  composed  of  about  96 
per  cent  by  weight  of  absolute  ether  (ethyl  oxid)  and  about  4 
per  cent  of  alcohol,  containing  a  little  water.  It  is  a  transparent, 
colorless,  mobile  liquid,  having  a  characteristic  odor  and  a  burning 
and  sweetish  taste.  It  is  soluble  in  about  ten  times  its  volume  in 
water  and  miscible  in  all  proportions  with  alcohol,  chloroform,  and 
fixed  and  volatile  oils.  It  boils  at  96°  F.  (35.5°  C).  Ether  is 
very  inflammable,  and  should  be  kept  in  tightly  stoppered  tin  cans 
in  a  cool  place. 

Average  Dose. — 15  minims   (1  C.c). 

Ethyl  Bromid;  JEthylis  Bromidum;  CJI^Br;  Bromic  Ether; 
Bromure  d'Ethyle,  F.  ;  Athylbromid,  Bromathyl,  G. 

Source  and  Character. — It  is  a  haloid  derivative,  prepared  by 
the  action  of  sulphuric  acid  on  alcohol  and  potassium  bromid.  It 
is  a  colorless,  highly  reactive,  very  volatile  liquid,  having  a  strong, 
ethereal  odor  and  a  sweetish,  warm  taste.  It  boils  at  about  103°  F. 
(39.4°  C),  and  burns  with  difficulty  with  a  green  flame.  It  is 
very  easily  decomposed  by  light  and  air,  turning  brown,  and  then 
containing  hydrobromic  acid.  It  should  not  be  confounded  with 
ethylen  bromid,  a  poisonous  compound. 

Ethyl  Chlorid;  ^thylis  Chloridum,  U.  S.  P.;  CjHgCl;  Anti- 

DOLERIN;  KeLENE;  NarCOTILE  ;  ChLORURE  d'EtHYLE,  F.  ;  ATHYL- 

chlorid,  Chlorathyl,  Gt. 

Source  and  Character. — It  is  a  haloid  derivative,  prepared  by 
the  action  of  hydrochloric  acid  gas  on  absolute  ethyl  alcohol.    On 


GENERAL   ANESTHETICS  349 

account  of  its  extreme  volatility  it  is  preserved  in  hermetically 
sealed  glass  or  metal  tubes.  It  is  a  colorless,  mobile,  very  volatile 
fluid,  having  a  characteristic  odor  and  burning  taste.  It  boils  at 
about  55°  F.  (12.8°  C),  and  burns  with  a  smoky,  green-edged 
flame.  When  liberated  from  its  container  it  vaporizes  at  once,  and 
the  resultant  gas  is  very  inflammable. 

Ethyl  chlorid  is  largely  employed  as  a  refrigerant  local  anes- 
thetic in  minor  surgery,  and  its  specific  application  for  such  pur- 
poses is  referred  to  under  Local  Anesthetics  and  Local  Anesthesia. 

MetJiyl  CMorid;  MetJiylis  CJiloridum;  CH3CI.  It  is  a  gaseous 
compound,  prepared  by  the  action  of  hydrochloric  acid  on  methyl 
alcohol  in  the  presence  of  zinc  chlorid.  It  is  a  colorless  gas,  having 
an  ethereal  odor.  Under  a  pressure  of  five  atmospheres  at  normal 
temperature  it  liquefies,  forming  a  colorless,  volatile  fluid.  It  boils 
at  about  —12°  F.  (—24.5°  C). 

Carbon  TetracJilorid;  TetracJilormetJian;  CCI4.  It  is  a  trans- 
parent, colorless  liquid,  having  an  agreeable  odor.  It  boils  at 
170°  F.  (76.8°  C).  It  is  not  used  as  an  anesthetic,  but  is  success- 
fully substituted  for  petroleum,  benzin,  gasolin,  etc.,,  over  which 
it  has  the  advantage  of  being  nonexplosive  and  noninflammable. 

Quite  a  large  number  of  hydrocarbons,  alcohols,  aldehyds, 
esters,  and  halogen  substitution  compounds  have  been  proposed  at 
one  time  or  another  as  general  anesthetics;  they  have  been  em- 
ployed only  sporadically,  and  after  a  short  sojourn  have  been  dis- 
carded. Among  the  more  prominent  members  of  these  groups  are 
pental,  ethylen  chlorid,  ethylidin  chlorid,  methylen  bichlorid,  and 
many  others.  Quite  a  large  number  of  compounds  of  these  groups., 
especially  of  the  aldehyds,  furnish  important  hypnotics — paralde- 
hyd,  sulphonal,  trional,  veronal,  urethan,  etc. 

Various  mixtures  consisting  principally  of  alcohol,  chloroform, 
ether,  ethyl  chlorid,  etc..  have  also  been  favored  as  general  anes- 
thetics. The  A.  C.  E.  mixture  of  Harley,  consisting  of  1  part  of 
alcohol,  2  parts  of  chloroform,  and  2  parts  of  ether,  also  known, 
when  compounded  in  somewhat  different  proportions,  as  Billroth 's 
mixture  and  the  C.  E.  mixture,  consisting  of  variable  proportions 
of  chloroform  and  ether,  are  prototypes  of  mixed  general 
anesthetics.  A  few  years  ago  Rolland,  of  Bordeaux,  introduced  a 
mixture  of  low  boiling  halogen  compounds  into  dentistry,  which 
is  known  as  somnoform.  It  consists  of  60  parts  of  ethyl  chlorid, 
35  parts  of  methyl  chlorid,  and  5  parts  of  ethyl  bromid.     Ex- 


350  PHARMACO-THERAPEUTICS 

travagant  claims  have  been  made  for  these  mixtures  by  its  vendors. 
Somnoform  is  by  no  means  the  "safest  of  all  anesthetics;"  a  few 
deaths  have  been  recorded  following  its  use,  and  as  soon  as  its 
name  disappears  from  public  print  it  will  be  forgotten,  as  it  offers 
no  advantage  over  pure  ethyl  chlorid. 

Physiologic  Action  of  the  Anesthetics  of  the  Methan  Series. 

Many  theories  have  been  promulgated  regarding  the  action  of 
general  anesthetics.  The  principal  theories  are  based  on  the  fol- 
lowing suppositions: 

The  absorbed  gases  partially  arrest  the  oxidation  as  carried  on 
in  the  tissues. 

The  chemic  character  of  the  red  blood  corpuscles  is  changed. 

The  anesthetic  possesses  a  peculiar  affinity  for  the  nerve  centers, 
and  acts  directly  through  the  nerve  cells  on  the  various  tissues. 

The  anesthetic  inhibits  the  function  of  the  nerve  centers,  and 
produces  anemia  of  the  brain. 

None  of  these  theories  explains  satisfactorily  the  action  of  nar- 
cotics. Recently  a  most  interesting  hypothesis  regarding  the  ac- 
tion of  anesthetics  of  the  methan  series  has  been  suggested  by 
Overton  and  Meyer,^  and  the  soundness  of  their  reasoning  has 
found  many  supporters  among  the  physiologists  and  pharmaco- 
logists. It  is  known  as  the  chemico-physical  theory  of  anesthesia. 
The  general  anesthetics,  wdth  the  exception  of  nitrous  oxid,  are 
volatile  organic  compounds  of  the  fatty  series.  The  action  of 
these  substances  depends  on  certain  specific  interchanges  which 
occur  between  the  drugs  and  the  chemic  constituents  of  the  gan- 
glion cells  of  the  cerebrum.  According  to  our  present  limited 
knowledge  regarding  the  composition  of  living  albumin,  we  are 
unable  to  explain  the  nature  of  these  changes,  but  it  is  plausible 
to  assume  that  this  union  between  the  drug  and  the  cell  albumin 
must  be  very  labile,  as  no  alterations  occur  within  the  cell  con- 
tents. Furthermore,  this  union  is  easily  broken  up,  as  anesthesia 
passes  off  quickly  after  the  narcotic  is  stopped,  and  the  patient 
awakens  without  apparent  serious  disturbances.  The  inter- 
changes which  occur  between  the  ganglion  cells  and  the  anesthetic 
depend  on  certain  chemico-physical  properties  of  the  anesthetic. 
It  is  most  important  that  the  narcotic  is  administered  in  vapor 

*  Overton:  Studien  uber  die  Narkose,  1901. 


GENERAL   ANESTHETICS  351 

form,  and  that  this  vapor  is  mixed  in  certain  proportions  with 
the  inspired  air,  so  as  to  bring  it  into  intimate  contact  with  the 
circulating  blood  in  the  alveoli  of  the  lungs.  The  blood,  which  is 
saturated  with  the  anesthetic  vapor,  carries  it  to  all  the  tissues 
of  the  body  but  the  ganglion  cells  possess  special  affinity  for  the 
narcotic  and  quickly  absorb  this  poison  from  the  blood.  If  the 
further  supply  of  the  anesthetic  is  now  stopped,  the  inner  pres- 
sure of  the  narcotic  vapor  present  in  the  blood  ceases,  the  gas  is 
exhaled  from  the  lungs,  and  the  blood,  which  is  now  free  from 
tension,  reabsorbs  the  anesthetic  from  the  ganglion  cells  and 
carries  it  to  the  lungs,  to  be  exchanged  for  normal  air.  This  proc- 
ess of  removal  is  continued  until  all  of  the  anesthetic  is  ex- 
changed for  normal  air.  Aside  from  the  inner  pressure  existing 
between  the  blood  and  the  lungs,  another  factor  plays  an  important 
role  in  regard  to  pharmacologic  action  in  general  and  in  anesthetic 
action  in  particular — it  is  the  solubility  of  the  narcotic  in  the  cell 
constituents.  All  protoplasm  contains  certain  fatty  substances 
composed  of  lecithin  and  cholesterin,  which  are  known  as  lipoids. 
The  ganglion  cells  are  especially  rich  in  lipoids,  and  they  are 
known  to  possess  a  special  affinity  for  narcotics.  Eecent  experi- 
ments have  shown  that  those  drugs  which  do  not  enter  into  living 
cells,  or  enter  only  with  difficulty,  are  more  or  less  insoluble  in 
fatty  oils,  but  they  are  readily  soluble  in  water.  On  the  other 
hand,  those  drugs  which  are  readily  soluble  in  oils  are  usually 
more  or  less  insoluble  in  water,  and  they  quickly  penetrate  into 
the  protoplasm  of  the  cells.  As  stated  above,  the  narcotic  acts 
on  all  tissue  cells,  but,  as  the  ganglia  are  especially  rich  in  lipoids, 
the  absorption  of  the  narcotic,  based  on  their  ready  solubility 
in  oils,  takes  place  very  rapidly.  To  explain  this  phenomenon  on 
a  physical  basis,  the  following  simple  test  will  elucidate  this 
factor:  A  saturated  solution  of  chloroform  in  water  (1  in  200) 
is  vigorously  agitated  with  a  fatty  oil  (cottonseed  oil)  ;  after  the 
separation  of  the  oil  and  water  has  taken  place,  the  chloroform 
will  be  dissolved  in  the  oil,  and  the  water  is  found  practically 
free  from  it. 

Some  years  ago  Schleich^  made  the  statement  that  an  anesthetic 
which  has  a  boiling  point  much  below  the  normal  temperature  of 
the  body  is  always  dangerous,  and  that  the  narcotic  which  boils 


*Schleich:  Schmerzlose  Operationen,   1902. 


352  PHARMACO-THERAPEUTICS 

slightly  above  the  normal  temperature  is,  relatively  speaking,  the 
safest  anesthetic.  This  statement  is  untenable,  as  shown  by  a  com- 
parison of  the  various  boiling  points  of  anesthetics.  The  boiling 
points  of  the  more  common  anesthetics  are  as  follows: 

Chloroform    141°  F.  (60.5°  C). 

Ethyl  bromid 103°  F.  (39.5°  C). 

Ether    96°  F.  (35.6°  C). 

Ethyl  chlorid   55°  F.  (12.8°  C.) . 

Methyl  chlorid   —  12°  F.  (—24.5°  C). 

Nitrous   oxid    —126°  F.  (—88°  C). 

A  comparison  of  the  boiling  points  of  these  various  anesthetics 
and  their  mixtures  leads  us  to  believe,  if  we  base  this  belief  on 
statistics  of  the  death  rate  from  their  administration  (see  follow- 
ing table),  that  the  lower  the  boiling  point  apparently  the  safer 
the  anesthetic.  Nitrous  oxid  has  the  lowest  boiling  point,  and  is  by 
far  the  safest  of  all  general  anesthetics.  A  comparison  of  the  tables 
seems  to  indicate  that  the  time  for  inducing  the  anesthesia,  its 
duration,  and  its  completeness  are  in  direct  ratio  with  the  boiling 
point  of  the  individual  anesthetic.  There  is  much  room  for  further 
elucidation  of  this  interesting  subject. 

Statistics  concerning  the  death  rate  from  the  various  anesthetics 
are  unreliable  guides  in  regard  to  their  safety.  Many  contributory 
factors,  which  it  is  impossible  to  exclude,  alter  the  relative  value 
of  these  statistics  to  such  an  extent  as  to  render  them  quite  prob- 
lematic. From  recent  statistics,  covering  1,146,493  narcoses,  the 
following  figures  are  obtained: 

Chloroform 1  death  in     3,500  administrations. 

Ether 1  death  in  26,268  administrations. 

C.  E.  mixture. . .   1  death  in     8,014  administrations. 

The  German  Central  Society  of  Dentists  has  prepared  a  series 
of  records  of  the  number  of  general  narcoses  and  their  fatalities, 
which  are  tabulated  from  the  reports  of  its  members,  covering  a 
period  of  four  years  (1902  to  1905).  These  statistics  resulted  in 
the  following  report: 

Chloroform  ...  1  death  in  42,215  administrations. 
Ethyl  bromid. .  1  death  in  121,154  administrations. 
Ethyl  chlorid..  No  death  in  70,630  administrations. 
Nitrous    oxid..   No  death  in     3,062  administrations. 


GENERAL   ANESTHETICS  353 

SYMPTOMS  OF   ANESTHESIA. 

The  action  of  an  anesthetic  on  the  general  system  may  be  con- 
veniently divided  into  three  stages — semi-unconsciousness,  excite- 
ment, and  anesthesia.  These  various  stages  are  more  defined  un- 
der chloroform  and  ether,  but  less  under  ethyl  chlorid,  and  still 
less  under  nitrous  oxid. 

The  first  stage  is  usually  ushered  in  by  the  feeling  of  choking, 
especially  when  ether  is  employed,  and  a  peculiar  v^armth  of  the 
whole  body.  The  senses  become  less  acute,  ringing  and  roaring 
in  the  ears  is  very  pronounced,  and  the  limbs  seem  to  become 
heavy  and  stiff.  The  pupils  enlarge,  the  face  becomes  flushed,  and 
the  pulse  is  slightly  accelerated,  while  the  respiration  is  more 
or  less  irregular.  The  second  stage,  or  excitement,  differs  very 
markedly  with  the  individual.  In  children  it  is  often  absent, 
while  it  is  usually  most  pronounced  in  those  addicted  to  alcohol. 
The  patient  exhibits  tremor  of  the  muscles,  with  stretching  of  the 
limbs,  and  often  tries  to  push  away  the  inhalation  mask.  Dream- 
like impressions  disturb  his  vanishing  consciousness,  and  he  may 
shout,  sing,  groan,  or  manifest  other  signs  connected  with  his 
mixed  thoughts  concerning  the  operation  or  his  surroundings. 
The  pulse  is  usually  very  irregular,  the  skin  is  flushed  and  cya- 
notic, and  the  pupils  remain  dilated.  With  the  progress  of  anes- 
thesia the  third  stage  is  reached — the  patient  becomes  quiet,  his 
muscles  relax,  the  face  assumes  a  calm,  death-like  appearance,  and 
the  reflexes  disappear.  The  respiration  becomes  more  regular 
again,  but  remains  shallow  and  slow.  As  soon  as  complete  anes- 
thesia is  reached,  extreme  care  is  necessary  to  prevent  the  respira- 
tion from  becoming  still  more  shallow.  After  the  narcosis  the 
patient  again  passes  through  a  stage  of  excitement,  although  less 
pronounced,  which  may  last  longer  than  the  initial  excitement. 
The  patient  usually  falls  asleep,  which  is  sometimes  interrupted 
by  nausea,  giddiness,  and  vomiting. 

Administration  of  Ethyl  Chlorid. 

The  administration  of  ethyl  chlorid  may  be  divided,  according 
to  the  method  employed,  into  three  different  modes,  and  each  one 
requires  specific  apparatus  for  its  correct  application. 

The  open  method  may  be  employed  in  two  forms.  One  consists 
in  spraying  or  dropping  the  ethyl  chlorid  on  a  flattened  cone  made 


354  PHARMACO-THERAPEUTICS 

of  surgical  gauze,  or  on  an  ordinary  chloroform  mask.  For  chil- 
dren and  anemic  patients  and  for  most  women,  the  mask  may  be 
arranged  as  for  an  ordinary  chloroform  anesthesia.  For  the  ma- 
jority of  patients,  however,  it  is  best  to  cover  the  gauze,  except 
at  the  center,  with  some  material  which  will  restrict  somewhat 
the  over-free  entrance  of  air  around  the  periphery.  Flannel  or 
similar  material  serves  well  for  covering  the  mask.  Herrenknecht, 
of  Freiburg,  uses  rubber  dam  and  finds  it  of  great  advantage. 


Fig.  69. 

Ethyl  chlorid  dropping  tube. 

Onto  the  gauze  exposed  by  the  central  opening  the  ethyl  chlorid 
is  carefully  dropped  or  sprayed  from  a  suitable  container. 

Objections  to  this  form  of  the  open  method  are;  first,  that  it 
wastes  ethyl  chlorid,  about  three  or  four  times  as  much  being 
necessary  as  when  a  Ferguson  mask  is  used.  Secondly,  by  it  the 
anesthesia  may  not  be  induced  as  quickly  or  easily  as  by  the  Fergu- 
son method. 

The  second  form  is  by  the  Ferguson  inhaler  which  is  preferred 

.6 


Fig.  70. 
Ferguson  inhaler. 

by  most  anesthetists  because  of  its  simplicity.  It  consists  of  a 
metal  frame,  mostly  of  very  fiexible  wire  so  as  to  permit  it  to 
be  molded  accurately  to  the  face.  It  has  a  convex  wire  diaphragm 
which  is  covered  with  a  few  layers  of  surgical  gauze.  The  whole 
is  encased  in  a  Canton  fiannel  hood,  having  a  top  opening,  the 
size  of  which  may  be  modified  at  will.  Through  this  opening  the 
ethyl  chlorid  is  dropped  or  sprayed  onto  the  gauze  diaphragm.  It 
is  more  economical  to  deliver  the  ethyl  chlorid  only  during  in- 


GENERAL   ANESTHETICS 


355 


spiration,  as  ethyl  chlorid  is  so  volatile  that  whatever  is  delivered 
while  the  patient  exhales,  is  blown  away  and  wasted.  If  during 
exhalation,  the  opening  G  (Fig.  70)  be  closed  with  the  fingers  and 
the  mask  tilted  to  allow  the  expired  air  to  escape  between  the 
inhaler  and  the  face,  the  induction  will  be  more  rapid  and  the 


^to: -NO.  .oiA»-l 

Ethyl  Chloride,   Squibb 

Tor   GENEPAL  ANACaTHMIA 

-1a;i!a;"^'^-^"'"*""""-'""i^- 


Fig.    71. 
Ethyl  chlorid  tube. 

quantity  of  ethyl  chlorid  used  reduced  to  a  minimum.  The  aver- 
age amount  of  anesthetic  used  by  the  Ferguson  method  is  30  to 
40  minims  (2  to  3  C.c.)  and  rarely  over  75  minims  (5  C.c). 

The  semi-open  method  consists  in  spraying  the    ethyl    chlorid 
into  an  inhaler  which  limits  the  intake  of  air  very  considerably. 


Fig.  72. 
Ermold-Stark  inhaler.     Sectional  view. 

Such  is  the  Ware  inhaler.  Some  of  these  instruments— such  as 
the  Seitz  mask — are  too  complicated  to  be  of  practical  use.  The 
open  method  of  ethyl  chlorid  administration  is  rarely  accom- 
panied by  nausea  or  vomiting.  This  is  probably  due  to  the  pres- 
ence of  an  abundance  of  fresh  air  and  the  avoidance  of  inspiring 
chlorinated  decomposition  products  as  occurs  in  the  semi-open  or 
in  the  closed  methods. 


356 


PHARMACO-THERAPEUTICS 


The  closed  method  requires,  in  the  main,  an  air-tight  bag  for 
the  retention  of  the  ethyl  chlorid  vapors,  provided  with  a  suitable 
inhaler.  An  ethyl  chlorid  tube  containing  45  to  75  minims  (3 
or  5  C.c.)  is  wrapped  in  cotton  and  placed  in  the  soft  rubber  bag 
of  a  Clover,  Dawbarn,  or  similar  inhaler;  breaking  the  tube  by 
pressure  through  the  walls  of  the  rubber  bag  releases  the  anes- 
thetic. Kecent  improved  inhalers  carry  a  special  tubular  arrange- 
ment for  breaking  the  ethyl  chlorid  tube  outside  of  the  bag  to 
prevent  the  entering  of  glass  splinters.  Quite  a  large  number  of 
special  inhalers  have  been  constructed  on  this  principle,  among 


Fig.  73. 
McFarlane's  ethyl  chlorid  inhaler. 

which  the  somnoform  inhaler  and  those  of  Robinson,  McFarlane, 
Lobjois,  Stark,  and  Green  are  probably  the  best  known.  The 
Ermold-Stark  inhaler  is  a  good  type  of  apparatus  to  be  used  for 
the  closed  method.  It  consists  of  a  metal  mask,  A,  with  inflated 
cushion,  B,  connected  with  a  rubber  reservoir,  C,  into  which  a 
magazine,  D,  opens.  This  magazine  is  made  to  hold  a  5-cubic- 
centimeter  tube  of  ethyl  chlorid,  which  is  broken  by  pressing  cap 
E  down.  Thus  the  ethyl  chlorid  escapes  as  a  gas  into  the  bag,  and 
is  readily  inhaled  through  the  mask.    G  is  a  valve  so  arranged  that 


GENERAL   ANESTHETICS 


357 


by  moving  knob  F  the  patient  may  be  made  to  gradually,  yet 
rapidly,  pass  from  the  breathing  of  pure  air  to  the  inhalation  of 
pure  ethyl  chlorid.  Broken  glass  can  not  enter  either  the  bag  or 
mask.  In  the  mask  is  a  metal  gauze  diaphragm  to  retain  surgi- 
cal gauze  in  order  to  permit  it,  when  removed  from  the  rest  of  the 
inhaler,  to  be  used  for  administering  ether  by  the  drop  method. 
If  preferred,  the  inhaler  may  be  charged  from  time  to  time  with 
ethyl  chlorid  by  removing   cap  E   and   spraying  into   the   bag 


Fig.  74. 
Gebauer  combination  inhaler. 


through  magazine  D  ethyl  chlorid  from  a  large  tube  with  auto- 
matic closure,  specially  gauged  for  general  anesthesia. 

Quite  a  different  principle  of  applying  a  continuous  small 
stream  of  ethyl  chlorid  is  involved  in  the  Gebauer  combination 
inhaler.  This  inhaler  is  favored  by  many  surgeons,  as  the  supply 
of  ethyl  chlorid  gas  is  always  under  perfect  control.  The  appa- 
ratus is  comparatively  simple  in  construction,  easily  sterilized,  and 
ether  may  be  administered  with  it  as  a  sequence  without  removing 
the  face  piece.    The  Gebauer  inhaler  consists  of  a  metal  cone  face 


358  PHARMACO-THERAPEUTICS 

piece,  A,  provided  with  a  pneumatic  air  pad,  B,  attached  around 
its  lower  edge.  On  top  of  the  cone  is  a  removable  casing  or  tap, 
C,  provided  with  an  exhaling  valve,  D,  and  a  tube  connection,  E. 
The  upper  portion  of  the  cone  is  provided  with  a  wire  frame 
work,  F,  interwoven  with  absorbent  gauze.  When  the  inhaler  is 
used  for  ether  or  chloroform  alone,  the  cap  is  removed  and  the 
anesthetic  is  dropped  on  the  absorbing  gauze,  the  same  as  when 
ether  or  chloroform  is  administered  by  the  drop  or  open  method. 
The  change  from  ethj^l  chlorid  to  ether  can  be  made  instantly  by 
simply  removing  the  top  cap,  C,  without  changing  the  position  of 
the  cone  on  the  face.  The  exhaling  valve,  D,  is  so  constructed  that 
it  will  permit  the  right  quantity  of  air  to  enter  into  the  inhaler 
with  every  inhalation,  and  also  allow  the  patient  to  exhale  freely, 
thus  avoiding  cyanosis.  The  vibrating  diaphragm  in  this  valve 
acts  also  as  an  indicator  for  the  respiratory  movements.  The  top 
of  the  container  is  provided  with  a  screw  valve,  which  regulates 
the  supply  of  ethyl  chlorid  vapors.  The  vapors  are  transmitted 
to  the  inhaler  by  means  of  the  rubber  tube,  I.  In  administering 
the  ethyl  chlorid,  the  container  is  held  in  the  right  hand,  the  warmth 
of  which  causes  the  ethyl  chlorid  to  vaporize,  and  by  opening  the 
valve  is  introduced  into  the  inhaler. 

Preparation  of  the  Patient. 

A  patient  who  wishes  to  undergo  an  operation  under  an  anes- 
thetic requires  certain  preparation.  This  preparation  varies  with 
the  nature  of  the  operation.  The  anesthetization  for  a  dental 
operation,  which  is  usually  completed  within  a  few  minutes  and 
which  is  conducted  under  nitrous  oxid  or  ethjd  chlorid,  requires 
a  less  elaborate  preparation  of  the  patient  than  a  major  operation 
under  chloroform  or  ether.  If  possible,  the  patient  should  have 
his  bowels  emptied  by  a  purgative,  given  the  night  before  the 
operation.  Very  little  food  should  be  taken  on  the  following 
morning — a  cup  of  tea  or  coffee  and  a  little  toast  are  sufficient  for 
breakfast.  The  best  time  to  operate  is  the  early  forenoon — at  9 
o'clock — as  the  body  is  at  its  highest  resistance  at  that  hour. 

Choice  of  the  Anesthetic. 

Nitrous  oxid  and  ethyl  chlorid  are  the  two  anesthetics  which 
are  principally  employed  in  the  United  States  and  England  for 


GENERAL   ANESTHETICS  359 

short  dental  operations,  while  in  other  countries,  especially  in  Ger- 
many and  Austria,  ethyl  bromid  is  probably  used  more  than  any 
other  anesthetic  for  such  purposes.  The  general  condition  of  the 
patient  will  determine  what  anesthetic  is  indicated  in  his  particu- 
lar case;  sex  and  age  are  of  little  consequence  in  regard  to  its 
choice,  and  the  very  young  and  elderly  patients  are  especially  good 
subjects  for  NoO  or  ethyl  chlorid.  Patients  suffering  from  bron- 
chitis and  pulmonary  tuberculosis  must  be  carefully  watched  to 
avoid  undue  cyanosis  if  N^O  is  given ;  a  liberal  supply  of  oxygen 
should  always  be  administered  with  it. 

According  to  Luke,^  the  available  time  for  the  various  anesthet- 
ics may  be  roughly  estimated  as  follows: 

Nitrous  oxid 30  seconds. 

Nitrous  oxid  aud  ethyl  chlorid....  90  to  120  seconds. 

Nitrous  oxid  (nasal  method) 1  to  5  minutes. 

Nitrous  oxid  and  ether 1  to  10  minutes. 

Ethyl  chlorid 1  to  2  minutes. 

Ethyl  chlorid  and  ether 1  to  10  minutes. 

Ethyl  chlorid  and  C.  E 2  to  5  minutes. 

C.  E.  mixture  and  ether  sequence. .  3  to  10  minutes,  or  ad  lib. 

For  the  average  dental  operation,  nitrous  oxid,  alone  or  in  com- 
bination with  oxygen,  is,  as  stated,  by  far  the  safest  of  all  anesthet- 
ics. On  account  of  the  somewhat  cumbersome  apparatus,  many 
operators  have  discarded  it  at  present  for  ethyl  chlorid  or  its  mix- 
tures. The  relative  safety  of  the  latter  compounds  is  much  less 
than  that  of  nitrous  oxid.  Chloroform  and,  to  some  extent,  ether 
should  not  be  employed  as  anesthetics  for  minor  dental  operations. 
The  many  deaths  which  have  occurred  from  the  use  of  chloroform 
in  dental  operations  probably  find  an  explanation  in  the  danger- 
ous upright  position  of  the  patient  when  seated  in  the  operating 
chair  and  in  incomplete  anesthesia  {Rausch  anesthesia). 

Treatment  of  Accidents  of  General  Anesthesia. 

The  disturbances  resulting  from  the  administration  of  anesthet- 
ics, which  to  a  more  or  less  degree  involve  the  various  functions 
and  tissues  of  the  body,  may  conveniently  be  classified  as  those 
affecting  first,  the  digestive  apparatus;  second,  the  circulation; 
third,  the  respiration ;  and  fourth,  the  nervous  system.  Disturb- 
ances in  the  digestive  apparatus  usually   manifest   themselves   in 

>Luke:  Guide  to  Anesthetics,  1906. 


360  PHARMACO-THERAPEUTICS 

two  distinct  varieties — in  nausea  and  in  vomiting.  By  nausea  we 
understand  that  well-known  sickening  feeling,  accompanied  by 
retching  and  a  desire  to  vomit.  It  is  the  direct  result  of  reflex 
movement  of  the  pharynx,  esophagus,  and  stomach,  and  is  most 
likely  caused  by  irritating  vapor  of  the  anesthetic.  It  is  pri- 
marily noticed  in  connection  with  the  administration  of  chloro- 
form, ether,  and  ethyl  bromid,  and  rarely  with  ethyl  chlorid  or 
nitrous  oxid.  Treatment  is  seldom  called  for,  as  nature  usually 
helps  herself.  If  we  wish  to  overcome  nausea  by  drug  administra- 
tion, small  doses  of  spirit  of  peppermint  or  of  valerian  prepara- 
tions are  recommended;  especially  validol,  a  compound  of  men- 
thol and  valerianic  acid,  deserves  to  be  mentioned.  Vomiting  re- 
sults from  complicated  conjoint  movements  of  the  diaphragm, 
the  stomach  walls,  and  the  glottis.  It  is  naturally  oftener  noticed 
in  cases  where  a  full  meal  is  taken  shortly  before  the  anesthetic 
is  administered;  it  rarely  occurs  in  laughing  gas  narcosis.  By 
vomiting  the  stomach  empties  itself,  and,  except  dieting  for  a  short 
time,  no  further  treatment  is  required.  It  is  essential  to  clear  the 
mouth  and  throat  from  all  vomited  matter  as  soon  as  possible  to 
avoid  obstruction  of  the  air  passages. 

Disturbances  of  the  circulation  are  very  dangerous.  While 
they  can  not  be  directly  obsei-ved  upon  the  organs  of  circulation 
or  the  blood,  fortunately  they  manifest  themselves  externally  to 
the  trained  eye  by  various  color  manifestations — cyanosis  or  ex- 
treme pallor.  Cyanosis  is  the  expression  of  severe  congestive 
hyperemia,  resulting  from  accumulation  of  venous  blood — a  sub- 
charge  of  carbon  dioxid.  The  blue  color  appears  primarily  on  the 
end  organs  of  the  body — the  lips,  cheeks,  fingers,  nose,  etc.  Cyanosis 
is  always  present  in  dyspnea  and  asphyxia.  Lipothymia,  or  faint- 
ing, is  a  temporary  inhibition  of  the  functions  of  the  brain,  result- 
ing from  cerebral  anemia,  usually  accompanied  by  more  or  less 
complete  inhibition  of  all  senses.  If  the  heart  should  stop  com- 
pletely, general  collapse  may  result.  A  specific  variety  of  col- 
lapse which  is  marked  by  the  suddenness  of  complete  heart  failure 
is  referred  to  as  syncope.  This  syncope,  when  occurring  in  the 
early  stages  of  administering  a  narcotic,  and  Avhen  accompanied 
by  a  typical  staring  of  enlarged  or  reduced  pupils,  indicates 
idiosyncrasy  to  the  narcotic  used.  The  treatment  of  the  disturb- 
ances of  circulation  consists  in  applying  mechanical  and  chemic 
means  to  bring  about  increased  or  renewed  heart  action.     Arti- 


GENERAL   ANESTHETICS  361 

ficial  respiration  and  powerful  rhythmic  compression  of  the  heart's 
region  are  essential.  The  compression  of  the  heart  is  best  accom- 
plished by  standing  on  the  left  side  of  the  patient,  and  forcefully 
pressing  with  the  right  thumb  into  the  region  between  the  apex 
of  the  heart  and  the  left  wall  of  the  sternum;  the  left  hand 
should  be  placed  over  the  right  thoracic  region  of  the  patient  to 
steady  the  body,  and  compression  should  be  applied  about  a  hun- 
dred times  a  minute.  Slapping  the  face  and  chest  of  the  patient 
with  towels  wrung  out  in  cold  water  acts  as  an  active  reflex  stimu- 
lant. Nelaton  suggests  lowering  the  head,  or  complete  inversion 
of  the  body,  to  promote  rapid  flow  of  blood  to  the  anemic  brain. 
Both  means  produce  excellent  results.  Stimulation  by  chemic 
agents  consists  of  applying  strong  irritating  substances  to  the 
nostrils.  In  the  early  stages  of  collapse,  ammonia,  in  the  form 
of  smelling  salts  or  in  its  various  solutions,  acetic  ether,  eau  de 
Cologne,  etc.,  are  indicated.  Camphor,  in  the  form  of  a  10  per 
cent  sterile  oil  solution  (in  ampuls)  and  injected  hypodermically 
is  the  supreme  remedy  in  collapse ;  it  stimulates  the  pathologically 
altered  heart  and  increases  the  frequency  and  activity  of  the 
heart  beat.  As  a  powerful  dilator  of  the  peripheral  vessels,  the 
vapors  of  amyl  nitrite  are  exceedingly  useful  by  placing  three  to 
five  drops  of  this  fluid  on  a  napkin  and  holding  it  before  the  nos- 
trils for  inhalation;  flushing  of  the  face  and  an  increase  of  the 
frequency  of  the  pulse  follow  almost  instantly.  Nitroglycerin 
solution  manifests  a  similar  typical  nitrite  action.  Aromatic 
spirit  of  ammonia,  in  halfteaspoonful  doses,  well  diluted,  is  much 
lauded  for  such  purposes.  Perfect  respiration  is  absolutely  es- 
sential to  aerate  the  blood  in  circular  disturbances. 

Disturbances  of  respiration  are  either  mechanical  or  functional 
in  their  nature.  To  avoid  possible  mechanical  obstruction  during 
narcosis,  which  may  occlude  the  trachea,  careful  inspection  of  the 
oral  cavity  should  always  be  resorted  to  before  beginning  to  anes- 
thetize. Artificial  teeth,  removable  bridges,  chewing  gum,  to- 
bacco, and  many  other  things  may  be  looked  for  in  the  mouth.  In 
extracting  teeth,  extreme  care  should  be  exercised  to  actually 
deposit  the  tooth  outside  of  the  mouth.  A  tooth  is  liable  to  spring 
from  the  forceps,  or,  when  forced  from  an  alveolus  by  an  elevator, 
may  fall  backward  and  enter  the  trachea.  To  avoid  such  an  oc- 
currence. Carter's  oral  net  spoon  has  been  devised.  If  the  slipped 
tooth  can  not  be  caught  with  the  finger  or  an  instrument,  an  effort 


362  PHARMACO-THERAPEUTICS 

should  be  made,  in  extreme  cases  only,  to  force  the  tooth  into  the 
gullet  by  pushing  it  backward  and  a  little  to  the  left,  thus  gaining 
entrance  into  the  esophagus. 

In  the  early  stages  of  anesthesia,  occasionally  inhibition  of 
respiration  is  produced  by  tonic  spasms  of  the  muscles  of  the 
tongue,  thus  forcing  this  organ  against  the  soft  palate  and  the 
posterior  wall  of  the  pharynx.  This  same  phenomenon  may  oc- 
cur during  profound  anesthesia  in  a  patient  assuming  a  recumbent 
position.  To  overcome  stenosis  of  the  larynx,  the  lower  jaw  should 
be  thrown  forward  by  pressing  against  the  two  rami  posteriorly. 
This  movement  is  known  as  Esmarch  (English)  or  Howard  grip. 
A  tongue  forceps  may  be  inserted  and  the  tongue  pulled  forward, 


Fig.  75. 
Artificial  respiration.     Expiration,  Sylvester's  method. 

or  even  piercing  the  tongue  with  a  needle  threaded  with  stout  silk 
and  applying  rhythmic  traction  has  been  resorted  to. 

The  typical  organic  impairments  of  respiration  are  known  as 
apnea,  dyspnea,  and  asphyxia.  The  differentiation  between  these 
three  forms  of  suffocation  rests  probably  more  with  the  severity 
of  the  disturbance  than  with  the  kind ;  they  are  primarily  the 
result  of  a  lesser  or  greater  paresis  of  the  respiratory  centers. 
The  supreme  remedy  is  artificial  respiration — an  artificial  means 
for  the  thorough  ventilation  of  the  blood  and  lungs,  replacing  the 
narcotic  with  air  until  normal  functions  of  the  organ  are  estab- 
lished. One  of  the  older  methods  of  forcing  air  into  the  system 
is  the  mouth-to-mouth  insufflation,  a  method  which  today  is  aban- 
doned; the  same  is  true  of  the  bellows  method.  Artificial  res- 
piration may  be  applied  by  any  of  the  known  methods  that  serve 


GENERAL    ANESTHETICS 


363 


its  purpose,  provided  the  employed  method  is  thoroughly  under- 
stood. 

Sylvester's  method  of  resuscitation  is  probably  most  universally 
employed.  It  is  carried  out  as  follows:  Place  the  patient  on  the 
back,  with  a  roll  of  clothing  under  the  shoulders.  Pull  the  tongue 
forward  and  retain  it  in  that  position  to  allow  the  free  entrance  of 
air  into  the  windpipe.  The  operator  stands  at  the  head  of  the 
patient  and  grasps  both  arms  midway  between  the  elbows  and 
wrist  joints;  the  arms  are  drawn  upward  until  the  hands  are  car- 
ried high  above  the  head,  and  kept  in  this  position  until  1,  2,  'd 
can  be  counted  slowly.    The  elbows  are  now  slowly  carried  down- 


Fig.  76. 

Artificial  respiration.     Inspiration,  Sylvester's  method. 


ward,  placed  by  the  side  of  the  trunk  and  inward  against  the 
chest.  This  movement  should  be  continued  at  the  rate  of  fifteen 
to  sixteen  times  a  minute,  and  may  be  continued  for  an  hour  or 
more  if  needed. 

Howard's  method  of  resuscitation  has  recently  been  advocated. 
It  is  carried  out  as  follows :  Place  the  patient  on  the  back,  with  a 
roll  of  clothing  under  the  thorax.  All  clothing  obstructing  the 
neck,  chest,  and  abdomen  must  be  loosened.  The  tongue  is  pulled 
forward  and  held  in  that  position  to  allow  the  free  entrance  of  air. 
Kneel  astride  the  patient's  hips  and  place  your  hands  on  his  chest; 
the  ball  of  each  thumb  rests  on  the  inner  margin  of  the  free  border 
of  the  costal  cartilages,  the  tip  of  each  thumb  is  near  or  on  the 
ensiform  cartilage,  and  the  finger  tips  are  placed  into  the  cor- 
responding intercostal  spaces.     The  elbows  of  the  operator  are 


364  PHARMACO-THERAPEUTICS 

firmly  pressed  against  the  patient's  sides  and  the  upper  portion 
of  his  hips.  Press  upward  and  inward  toward  the  diaphragm,  and 
throw  the  weight  slowly  forward  two  or  three  seconds  until  the 
face  almost  touches  that  of  the  patient,  ending  with  a  sharp  push, 
which  helps  to  jerk  the  operator  back  to  the  erect  kneeling  posi- 
tion. Now  rest  three  to  five  seconds,  and  repeat  the  same  move- 
ment at  the  rate  of  seven  to  ten  times  a  minute  until  natural  res- 
piration is  established. 

Faradization  of  the  diaphragm  is  sometimes  useful;  too  much 
should  not,  however,  be  expected  from  the  electric  current  in  this 
connection.  Dilating  the  anus  with  a  suitable  speculum  is  also 
recommended.  A  careful  and  quickly  instituted  artificial  respira- 
tion is  the  alpha  and  omega  of  all  methods  of  resuscitation.  The 
proper  use  of  the  first  minute  is  of  more  real  value  in  the  preserva- 
tion of  the  extinguishing  life  than  all  the  hours  thereafter.  No 
precious  moments  should  be  lost  by  rubbing  the  patient,  applying 
smelling  salts,  or  other  secondary  means.  Artificial  respiration 
may  often  be  profitably  continued  for  an  hour  or  longer  until 
fairly  normal  lung  activity  is  established. 

As  far  as  medication  is  concerned,  the  only  drug  that  has  proved 
to  be  of  value  in  this  connection  is  strychnin  in  full  doses  by  means 
of  hypodermic  injections. 

Nervous  disturbances  during  or  following  anesthesia  usually 
manifest  themselves  in  two  definite  forms — in  those  affecting  the 
psyche  and  those  unbalancing  the  motor  centers.  Psychic  ex- 
citement is  a  common  occurrence  in  the  preliminary  stages  of 
narcosis;  hysterics  and  alcoholics  furnish  by  far  the  largest  con- 
tingent. Intense  muscular  exertion,  combined  with  clonic  or  tonic 
spasms,  frequently  result  in  an  increased  pulse  rate,  with  more 
or  less  cyanosis  and  stertorous  respiration.  If  we  possess  an  anam- 
netic  clue  in  regard  to  existing  hysteria  or  alcoholism,  a  hypoder- 
mic injection  of  morphin  half  an  hour  before  beginning  of  the 
narcosis  will  materially  lessen  this  preliminary  excitement.  Oc- 
casionally we  meet  a  patient  who  will  awake  from  the  anesthetic 
with  apparent  normal  physical  condition,  but  without  perfect  con- 
trol of  the  sensorium.  The  patient  remains  for  some  minutes  in 
a  sort  of  lethargic  sleep,  which  may  at  times  reach  a  deep  comatose 
state.  Smelling  salts  held  to  the  nostrils,  cold  water  dashed  in 
the  face,  and  loud  talking  or  shaking  ■will  arouse  the  patient.  Dis- 
turbances of  the  motor  centers  result  in  more  or  less  severe  spasm. 


GENERAL   ANESTHETICS  365 

Singultus,  the  ordinary  hiccough,  is  often  seen  in  the  early  stages 
of  inhalation.  Tremor  of  a  single  group  of  muscles  or  of  the 
entire  body  is  noticed  more  or  less  frequently  after  the  taking  of 
smaller  quantities  of  the  narcotic;  similar  tremors  as  a  result  of 
indulging  in  other  narcotics — as  tea,  coffee,  or  tobacco — are  no- 
ticed in  those  who  are  not  habitues  of  these  drugs.  These  muscle 
tremors  are  usually  confined  to  the  early  stages  of  inhalation,  and 
are  not  dangerous.  If  they  should  occur  after  the  anesthetic 
passes  off,  the  strong  will  power  of  the  patient  materially  assists 
in  readily  overcoming  these  tremors.  Convulsions,  combined  with 
clonic  or  tonic  spasms,  occur  frequently  under  nitrous  oxid  anes- 
thesia, but  much  less  under  the  other  narcotics.  Care  should  be 
exercised  to  prevent  the  patient  from  hurting  himself.  The  re- 
moval of  the  anesthetic  quickly  relieves  the  condition.  Tetanus — 
the  persistent  contraction  of  voluntary  muscles — is  frequently  seen 
in  the  early  stages  of  anesthesia;  less,  however,  when  chloroform 
is  used.  Typical  trismus — tonic  spasms  of  the  muscles  which  are 
supplied  by  the  fifth  pair  of  nerves,  especially  those  of  mastica- 
tion— is  often  very  troublesome  in  dental  anesthesia.  As  a  pre- 
caution, a  suitable  mouth  prop  should  always  be  put  in  place. 
Severe  forms  of  tetanic  convulsions,  bending  the  head  and  feet 
backward,  known  as  opisthotonos,  are  also  seen  under  anesthesia 
in  the  early  stages.  All  these  muscle  disturbances  rarely  call  for 
treatment,  but  carefully  watching  the  patient  to  prevent  hurting 
himself  is,  however,  indicated. 

In  surgical  literature  reference  is  frequently  made  to  "shock 
from  anesthetics."  According  to  Crile,^  "shock  is  the  result  of 
excessive  conversion  of  potential  into  kinetic  energy  in  response 
to  adequate  stimuli."  In  other  words,  shock  and  exhaustion  seem 
to  be  identical  and  it  seems  immaterial  what  causes  their  produc- 
tion. * '  Since  shock  is  the  result  of  over-activation  and  consequent 
exhaustion  of  the  kinetic  system,  however  that  condition  has  been 
induced,  then  the  two  important  points  to  be  borne  in  mind  in  its 
treatment  are  (1)  the  prevention  of  further  shock  by  the  ameli- 
oration or  elimination  of  the  conditions  which  produce  it;  and 
(2)  the  support  of  the  circulation:  in  other  words,  (1)  the  energy 
still  remaining  in  the  kinetic  system  must  be  preserved;  and  (2) 
the  destructive  effects  of  anemia  must  be  overcome.''    To  overcome 


1  Crile  and  Lower:  Anoci-association,  Philadelphia,  1915. 
'  Crile  and  Lower:  Loc.  cit. 


366  PHARMACO-THERAPEUTICS 

these  difficulties,  the  surgeon  "must  check  hemorrhage;  he  must 
relieve  pain;  he  must  remove  anxiety  and  distress.  Even  in  those 
cases  of  shock  which  have  suffered  their  misfortune  before  the 
surgeon  sees  them  he  can  assist  greatly  by  helping  to  blunt  the 
sensibilities  and  to  quiet  apprehension.  For  this  purpose  morphin 
is  the  surgeon's  sheet-anchor."  (Mumford.)  Based  upon  the 
above  conceptions,  Crile  has  built  up  a  system  of  so-called  anoei- 
association,  i.  e.,  "sequestering  the  brain  from  the  field  of  opera- 
tion by  blocking  the  nerves."  While  Crile  has  achieved  brilliant 
results  in  his  operating  room,  his  assertions  have  not  been  gen- 
erally accepted  by  surgeons  and  physiologists. 

For  the  purpose  of  readily  meeting  unexpected  side  effects  of 
anesthetics,  every  practitioner  should  provide  himself  with  a  stock 
of  emergency  drugs,  placed  in  an  easily  accessible  compartment 
of  his  medicine  chest,  consisting  of: 

Hypodermic  tablets  of  strychnin  sulphate,  Yso  grain. 

Hypodermic  tablets  of  morphin  sulphate,  %,  %  and  14  grain. 

Sterile  camphorated  oil,  10  per  cent,  in  ampuls. 

Amyl  nitrite,  in  5-drop  glass  capsules. 

Aromatic  spirit  of  ammonia. 

Smelling  salts. 

Whisky. 

Hypodermic  syringe  in  good  working  order. 

HYPNOTICS. 

Hypnotics  (sleep  producers),  sometimes  referred  to  as  sopo- 
rifics or  somnifacients,  are  drugs  applied  for  the  purpose  of  in- 
ducing sleep.  Incidentally  they  relieve  pain  by  paralyzing  cer- 
tain parts  of  the  cerebrum,  and  consequently  they  are  closely  re- 
lated to  general  anesthetics,  narcotics,  anodynes,  and  analgesics. 
From  the  viewpoint  of  the  pharmacologist,  hypnotics  can  not  be 
classified  as  a  specific  group  of  remedies,  but  for  clinical  purposes 
this  grouping  answers  satisfactorily.  Some  of  the  hypnotics  are 
soluble  in  water,  others  are  not;  all  are,  however,  soluble  in  fatty 
oils.  No  plausible  explanation  has  as  yet  been  offered  regarding 
the  action  of  hypnotics.  Sleep  and  wakefulness  are  periodical 
functions  of  the  central  nervous  system,  which  occur  at  rhythmical 
intervals.  These  periodical  functions  are  often  irritated  by  ex- 
ternal  and  internal  disturbances.     Physical   and  mental  strain, 


HYPNOTICS  367 

nervous  diseases,  lessened  resistance,  and  many  somatic  disturb- 
ances are  frequent  causes  of  insomnia.  Sleep  should  not  be  arti- 
ficially induced  at  once  in  every  ease  in  which  the  patient  com- 
plains of  insomnia;  regulating  the  diet,  proper  exercise,  eliminat- 
ing the  nervous  disturbances,  lukewarm  baths,  etc.,  are  of  prime 
importance  in  inducing  natural  sleep.  Hypnotics  should  not  be 
given  for  an  extended  time,  as  they  are  very  prone  to  create  habits. 
It  is  often  advisable  to  change  the  remedy  at  short  intervals  if  it 
must  be  given  for  a  long  period. 

Hydrated  Chloral;  Chloralum  Hydratum,  U.  S.  P.;  Choral 
Hydras,  B.  P.;  C2HCI3O+H2O;  Hydrate  de  Chloral,  F. ; 
Chloralhydrat,  G. 

A  crystalline  solid,  having  an  aromatic,  penetrating,  and  slight- 
ly acrid  odor  and  a  bitter,  caustic  taste.  It  is  freely  soluble  in 
water,  alcohol,  ether,  chloroform,  and  fixed  and  volatile  oils.  It 
is  usually  prescribed  in  diluted  solutions,  syrup,  etc.  Its  irritant 
properties  prohibit  its  use  for  hypodermic  purposes. 

Average  Dose. — 8  grains  (0.5  Gm.),  repeated,  if  necessary,  in 
one  or  two  hours. 

SulpJionmethan ;  SulphonmetJianum,  U.  S<  P. ;  Sulphonal,  B. 
P. ;  C7HieS204.  A  white  powder  or  colorless  crystals,  without 
odor  and  taste.  It  is  soluble  in  360  parts  of  water  and  47  parts 
of  alcohol.  It  is  usually  administered  in  powder  form,  followed 
by  a  cup  of  hot  milk,  an  hour  or  two  before  retiring.  Average 
dose,  15  grains  (1  Gm.). 

SulpJionethylmethan;  SulpJionetJiylmetJianum,  U.  S.  P. ;  CgHja 
S2O4;  Trional.  It  closely  resembles  sulphonal,  but  is  more  soluble. 
Average  dose,  15  grains  (1  Gm.). 

Paraldehyd;  Paraldehydum,  U.  S.  P. ;  B.  P. ;  CcHigOg.  A  color- 
less, transparent  fluid,  having  a  strong,  characteristic  odor  and  a 
burning  taste.  It  is  preferably  prescribed  in  weak  alcoholic  solu- 
tions.   Average  dose,  30  minims  (2  C.c). 

Butylchloral  Hydrate;  Butylchloral  Hydras,  B.  P. ;  C4H7O2CI3 ; 
Croton  Chloral  Hydrate.  It  resembles  chloral  hydrate  very  closely 
in  its  action,  but  it  is  said  to  be  less  depressing  and  more  analgesic. 
It  has  been  especially  recommended  in  facial  neuralgia.  Average 
dose,  15  grains  (1  Gm.). 

Ethyl  Carbamate;  ^thylis  Carhamas,  U.  S.  P. ;  CsH^NOj ; 
Urethan.    Colorless  crystalline  masses,  with  a  cool,  saline  taste.    It 


368  PHARMACO-THERAPEUTICS 

is  soluble  in  1  part  of  water,  0.6  parts  of  alcohol,  ether,  etc.  Aver- 
age dose,  15  grains  (1  Gm.). 

Veronal;  Veronalum;  CgHjaOsNg;  Dietliylmalonylurea.  It  is  a 
white  crystalline  powder,  odorless,  and  faintly  bitter  to  the  taste. 
It  is  soluble  in  about  150  parts  of  water.  It  is  best  given  in 
powder  form,  followed  by  a  cup  of  hot  milk  or  tea.  In  small 
doses  it  is  claimed  to  be  a  relatively  safe  hypnotic.  Average  dose, 
71/2  grains  (0.5  Gm.). 

There  are  a  large  number  of  other  hypnotics  which  have  been 
more  or  less  prominent  before  the  profession,  among  which  are 
amylen  hydrate,  chloretone,  hedonal,  isopral,  petronal,  etc. 

Sleeping  Draughts. 

R     Chlorali  hydrati  3  ij    (8.0  Gm.) 

Syr.  liinonis 
Aquae  aa  fl^  ss  (15  C.c.) 

M. 

Sig. :     Teaspoonf ul  in  half  a  glass  of  water  an  hour  before 
retiring. 

For  Facial  Neuralgia. 

IJ     Butyli  chlorali  hydrati  3  jss   (6.0  Gm.) 

Syr.  limonis  flS  ss  (15  C.c.) 

Aquae  ad  flS  ij   (60  C.c.) 

M. 

Sig.:     Teaspoonf  ul  in  half  a  glass  of  water,  followed  in 
ten  minutes  by  a  second  dose. 

ANODYNES. 

Anodynes,  sometimes  referred  to  as  analgesics  (without  or 
against  pain)  and  as  narcotics  (to  stupefy),  are  remedies  employed 
for  the  purpose  of  relieving  pain.  By  pain  we  understand  the 
conscious  manifestation  of  morbid  changes  within  the  nerve 
centers  caused  by  some  form  of  irritation,  and  it  is  usually  mani- 
fested at  the  periphery.  Anodynes  are  administered  internally, 
and  act  by  inhibiting  the  sensory  functions  of  the  central  nervous 
system.  They  do  not  form  a  specific  pharmacologic  group  of 
remedies,  but  are  closely  related  in  their  general  action  to  the  gen- 
eral anesthetics.  The  action  of  the  latter  group  inhibits  not  alone 
the  sensory  functions,  but  also  the  motor  functions  and  con- 
sciousness.    When  anodynes  are  locally  applied,  they  are  often 


ANODYNES  369 

referred  to  as  local  anesthetics.  General  anesthetics  are  rarely 
employed  for  the  purpose  of  relieving  pam,  and  are  principally 
used  to  prevent  pain.  The  foremost  drugs  which  are  employed 
to  relieve  pain  are  opium  and  its  alkaloids  and  certain  compounds 
of  the  aromatic  series.  The  latter  are,  however,  principally  used 
to  reduce  the  temperature  of  the  body,  and  thereby  they  may  act 
indirectly  as  antineuralgics.  The  most  important  anodyne  is 
morphin ;  it  is  the  sovereign  remedy  in  all  cases  where  severe  pain 
has  to  be  controlled. 

Opium  ;  Opium,  U.  S.  P.,  B.  P. ;  Opium,  F.  G. 

It  is  the  dried  milky  exudation  obtained  by  incising  the  unripe 
capsules  of  the  opium  plant,  Papaver  somniferum.  It  should 
yield,  when  moist,  not  less  than  9  per  cent  of  crystallized  morphin. 
Opium  contains  numerous  alkaloids  of  which  about  twenty  have 
been  isolated.  The  principal  opium  alkaloids  are:  Morphin,  10 
per  cent,  codein,  0.3  per  cent,  thebain,  0.4  per  cent,  narcotin,  5 
per  cent,  narcein,  and  papaverin.  Pantopon  and  narcophin  are 
artificial  mixtures  claimed  to  represent  the  total  alkaloid  of  opium, 
as  a  unit,  in  the  form  of  the  soluble  hydrochloric  salts  and  fire 
from  inert  vegetable  matter. 

Average  Dose. — 1  grain  (0.06  Gm.). 

Preparations. — 

Granulated  Opium;  Opii  Pulvis,  U.  S.  P.;  Dried  Powdered 
Opium.  It  should  yield  10  per  cent  of  crystallized  morphin.  Aver- 
age dose,  1  grain  (0.06  Gm.). 

Tincture  of  Opium;  Tinctura  Opii,  U.  S.  P.,  B.  P. ;  Laudanum; 
Teinture  Tkehaique,  F. ;  Opiumtinktur,  G.  It  contains  10  per  cent 
(about  lyo  per  cent,  B.  P.)  of  opium.  Average  dose,  8  minims 
(0.5  C.c.)  ;  15  minims  (1  C.c),  B.  P. 

Tincture  of  Deodorized  Opium;  Tinctura  Opii  Deodorati,  U.  S. 
P.  It  contains  10  per  cent  of  opium.  Average  dose,  8  minims 
(0.5  C.c). 

Camphorated  Tincture  of  Opium;  Tinctura  Opii  Camphorata, 
U.  S.  P.;  Tinctura  CampJiorce  Composita,  B.  P.;  Paregoric.  It 
contains  4  parts  of  opium  in  1,000  parts  of  the  tincture.  Average 
dose,  1  fluidram  (4  C.c). 

Morphin  Acetate;  Morphince  Acetas,  B.  P.;  C17H19NO3.C2H4O2 
+3H2O.    A  white  or  yellowish  crystalline  powder,  having  a  slight 


370  PHARMACO-THERAPEUTICS 

odor  and  a  bitter  taste.  It  is  soluble  in  about  2.5  parts  of  water  and 
25  parts  of  alcohol.    Average  dose,  i/s  grain  (0.008  Gm.). 

Morphin  Hydroclilorid;  Morpliinm  Ilydrocliloridum,  U.  S.  P.. 
B.  P. ;  C17H19NO3.HCI+3H2O.  It  appears  in  white,  silky,  glisten- 
ing needles,  or  in  small  crystalline  cubes,  odorless,  and  having  a 
bitter  taste.  It  is  soluble  in  about  20  parts  of  water  and  50  parts 
of  alcohol.    Average  dose,  i/g  grain  (0.008  Gm.). 

MorpJiin  Sulpliate;  Morpliinm  Sidplias,  U.  S.  P.;  (Ci7Hi9N03)2- 
H2SO44-5H2O.  White,  feathery  crystals  or  cubical  masses,  odor- 
less and  having  a  bitter  taste.  It  is  soluble  in  about  16  parts  of 
water  and  about  500  parts  of  alcohol.  Average  dose,  ^8  grain 
(0.008  Gm.). 

Solution  of  MorpTiin  HydrocMorid;  Liquor  MorpMnce  Hydro- 
cJdoridi,  B.  P.  A  1  per  cent  solution  of  morphin  hydrochlorid. 
Average  dose,  15  minims  (1  C.c). 

Hypodermic  Morpliin  Injection;  Injectio  MorpMnce  Hypoder- 
niica,  B.  P.  It  contains  1  per  cent  of  morphin  tartrate,  and  is  used 
for  hypodermic  injections.     Average  dose,  4  minims   (0.25  C.c). 

Codein  PJiospliate;  Codeince  Pliosplias,  U.  S.  P.,  B.  P.;  Ci(,H2i 
NO3.H3PO4+2H2O.  It  appears  in  fine  white,  needle-shaped  crys- 
tals, or  as  a  crystalline  powder,  odorless,  and  having  a  very  bitter 
taste.  It  is  soluble  in  about  2.5  parts  of  water  and  255  parts  of 
alcohol.    Average  dose,  i/^  grain  (0.03  Gm.). 

Compound  Powder  of  Morphin;  Pulvis  Morphine  Compositus; 
Tully's  Powder.  It  contains  1.5  per  cent  of  morphin  sulphate,  to- 
gether with  camphor,  licorice,  and  calcium  carbonate.  Average 
dose,  7I/2  grains  (0.5  Gm.). 

Powder  of  Ipecac  and  Opium;  Pulvis  IpecacuanJice  et  Opii, 
U.  S.  P.;  Pidvis  IpecacuanJuB  Compositus,  B.  P.;  Dover's  Powder. 
It  contains  10  parts  of  ipecac,  10  parts  of  opium,  and  80  parts  of 
sugar  of  milk.    Average  dose,  71/2  grains  (0.5  Gm.). 

Therapeutics. — Morphin,  when  given  in  average  doses,  in- 
hibits the  entire  function  of  the  cerebrum,  and  thereby  abolishes 
sensibility  to  pain  and  produces  sleep.  It  reduces  the  irritability 
of  the  centers  of  respiration,  and  almost  invariably  contracts  the 
pupils,  but  this  latter  action  is  not  utilized  therapeutically.  The 
circulation  is  not  affected  by  morphin.  The  peristaltic  move- 
ment of  the  bowels  is  usually  lessened  by  this  narcotic. 


ANODYNES  371 

Morphin  is  a  powerful  poison,  and  kills  by  paralyzing  the  cen- 
ters of  respiration.  Man  is  by  far  the  most  sensitive  being  as  re- 
gards the  action  of  morphin.  The  lower  the  organization  of  the 
animal,  the  less  reaction  is  produced  by  this  poison.  Bacteria  are 
not  influenced  by  its  solution.  Small  children  are  very  sensitive 
to  opium  and  morphin;  even  very  small  doses  may  produce  dan- 
gerous symptoms. 

Morphin  is  readily  absorbed,  especially  when  injected  hypo- 
dermically,  and  manifests  its  action  within  a  few  minutes.  In 
most  people  it  produces  at  first  very  slight  excitement,  which  is 
immediately  followed  by  psychic  rest  and  a  feeling  of  content- 
ment, with  more  or  less  inhibition  of  volition.  A  state  of  general 
analgesia  results,  without  interfering  markedly  with  the  cerebral 
functions.  Morphin  does  not  produce  general  or,  when  applied 
externally,  local  anesthesia.  In  due  time  drowsiness  results,  which 
soon  passes  into  sleep ;  the  latter  lasts  from  eight  to  twelve  hours. 
On  awakening,  a  slight  dizziness,  loss  of  appetite,  and  constipation 
are  often  experienced.  Large  doses  of  morphin  produce  a  comatose 
condition;  all  reflexes  are  abolished,  the  face  looks  sallow  and 
cyanosed,  the  eyeballs  are  turned  upward,  and  the  pupils  are  con- 
tracted. The  respiration  becomes  shallow,  and  is  interrupted  by 
the  Cheyne-Stoke  breathing.  Eespiratipn  ceases  entirely  before 
the  heart  beat  stops  its  final  action.  In  poisoning  with  morphin, 
even  when  given  hypodermically,  it  is  often  found  in  the  stomach. 
The  stomach  should  always  be  thoroughly  washed,  and  the  patient 
must  be  kept  awake  and  in  motion  if  at  all  possible.  Artificial 
respiration,  even  after  life  seems  to  be  extinct,  should  be  persist- 
ently applied.  The  injection  of  full  doses  of  strychnin  is  indi- 
cated. 

The  continuous  use  of  morphin  readily  leads  to  an  addiction  to 
the  drug.  Extreme  care  should  be  exercised  in  prescribing  larger 
quantities  of  morphin  for  prolonged  use,  and  under  no  condi- 
tions should  the  patient  be  allowed  to  administer  a  hypodermic 
injection  to  himself.  Sufferers  from  persistent  cases  of  facial  neu- 
ralgia frequently  become  habitues  of  this  poison. 

Morphin  is  the  supreme  analgesic,  and  will  reduce  the  most 
persistent  and  apparently  unbearable  pain.  It  should  not,  how- 
ever, be  used  indiscriminately  on  account  of  the  possibility  of  in- 


372  PHAKMACO-THEUAPEUTICS 

ducing  morphinism.  Morphin  should  always  be  substituted  by 
some  other  analgesic  if  possible,  and  it  should  be  used  only  in  cases 
of  absolute  necessity.  Pain  arising  from  certain  forms  of  acute 
alveolar  abscesses,  difficult  eruption  of  a  lower  third  molar,  etc., 
may  call  for  its  administration.  Morphin  is  very  beneficial  in 
diseases  of  the  respiratory  apparatus.  Applied  to  an  exposed  pulp, 
either  alone  or  combined  with  arsenic,  morphin  has  no  action. 
(See  Arsenic  Trioxid.) 

Aconite;  Aconitum,  U.  S.  P.;  Aconiti  Radix,    B.    P.;    Monk's 
Hood;  Wolfsbane;  Aconite  Napel,  F. ;  Eisenhut,  G. 

Source  and  Character. — It  is  the  dried  tuberous  root  of 
Aconitum  napellus.  Its  principal  constituent  is  the  alkaloid 
aconitin.  The  latter  is  insoluble  in  water,  but  readily  soluble  in 
alcohol. 

Average  Dose. — 1  grain  (0.065  Gm.). 

Preparations. — 

Tincture  of  Aconite;  Tinctura  Aconiti,  U.  S.  P.,  B.  P.  A  hydro- 
alcoholic  solution  of  the  active  constituents  of  aconite.  Average 
dose,  5  minims  (0.3  C.c). 

The  strength  of  the  tincture  of  aconite  of  the  present  U.  S.  P.  has 
been  reduced  from  35  grams  of  aconite  in  100  cubic  centimeters 
(U.  S.  P.  1890)  to  10  grams  of  aconite  in  100  cubic  centimeters. 

Therapeutics. — Aconite  is  principally  employed  in  the  form  of 
the  tincture.  The  alkaloidal  content  of  the  tuber  differs  greatly 
with  the  soil  on  which  it  is  grown,  and  on  account  of  its  very 
poisonous  nature  the  alkaloid  is  rarely  employed  internally.  The 
active  principles  of  aconite,  as  presented  in  the  liquid  prepara- 
tions, readily  decompose  on  standing,  hence,  in  prescribing,  fresh 
preparations  should  be  insisted  upon.  Aconite  is  a  powerful  poi- 
son; it  slows  and  weakens  the  heart  and  circulation,  and  quickly 
paralyzes  the  respiratory  centers.  As  it  reduces  the  temperature, 
it  has  been  quite  in  favor  in  the  past  as  an  antipyretic,  especially 
in  children's  diseases.  Locally  applied,  tincture  of  aconite  be- 
numbs the  terminations  of  the  sensory  nerves  of  the  skin  and  the 
mucous  membranes;  hence  its  use  in  dentistry  as  a  local  anodyne 
and  as  a  supreme  remedy  for  facial  neuralgia.  It  deserves  to  be 
recommended  in  the  form  of  a  liniment  or  ointment,  especially 
when  combined  with  menthol,  or  given  internally  in  the  form  of 


ANODYNES  373 

a  potent  tincture  in  full  doses.  A  mixture  of  equal  parts  of  tinc- 
ture of  aconite  and  tincture  of  iodin,  which  is  very  largely  used  in 
dentistry  as  an  anodyne  and  a  counterirritant,  is  of  little  practical 
value;  the  official  tincture  merely  dilutes  the  iodin  solution.  The 
aconite  represented  in  this  mixture  is  entirely  too  small  to  be  of 
benefit,  and,  if  a  concentrated  tincture  (fluidextract)  is  used,  the 
possibility  of  its  quick  absorption  and  subsequent  untoward  ef- 
fects courts  danger. 

Toxicology, — If  a  large  dose  of  tincture  of  aconite  is  ab- 
sorbed, a  peculiar  feeling  of  warmth  in  the  mouth  and  the  throat 
is  manifested.  It  is  followed  by  a  pricking  and  tingling  sensa- 
tion, and  accompanied  by  a  profuse  flow  of  saliva  and  frequent 
vomiting.  Death  results  from  paralysis  of  the  respiratory  centers. 
Emetics,  strong  coffee,  and  tea  are  indicated,  together  with  general 
stimulants. 

Anodyne  Compounds  for  Facial  Neuralgia. 

B     Menthol.  3  j   (4  Gm.) 

Chloroform.  fl3  ij   (8  C.c.) 

Tinct.  aconiti  ad  flS  j   (30  C.c.) 

M. 

Sig. :     Apply  externally  on  the  painful  areas  of  the  face 
and  cover  with  cotton. 

B     Aconitinae  gr.  ij   (0.125  Gm.) 

Menthol.  3  ij   (8.0  Gm.) 

Methyl,  salicyl.  fl3  ij   (8  C.c.) 

Lanolini  ad  S  j   (30.0  Gm.) 

M.  f.  unguentum. 

Sig.:     Rub  on  the  painful  areas  of  the  face  and  cover 
with  cotton. 

For  Pericemental  Disturbances. 

B     Tinct.  aconiti 
Tinct.  iodi 
Chloroform!  aa  fl3  j   (4  C.c.) 

M. 

Sig. :     Dry  the  gum  and  apply  over  the  affected  tooth. 

Atropin  Sulphate;  Atropine  Sulphas,  U.  S.  P.,  B.  P.; 

(C„H23N03).H3SO,. 
It  is  the  sulphate  of  an  alkaloid  obtained  from  Atropa  bella- 
donna.   It  appears  as  a  white  crystalline  powder,  having  a  very 


374  PHARMACO-THERAPEUTICS 

bitter  taste.  It  is  very  soluble  in  water  and  alcohol.  Atropin  is 
used  in  dentistry  as  a  physiologic  remedy  for  arresting  or  lessen- 
ing secretions  (see  Sialogogues  and  Antisialogogues),  and  as  an 
anodyne;  it  is  much  inferior  to  aconite  for  the  latter  purpose. 
Its  other  specific  functions  on  the  eye  and  central  nervous  sys- 
tem are  of  less  importance  for  our  present  consideration.  It  is  a 
yery  powerful  poison. 
Average  Dose. — %2o  grain  (0.0005  Gm.). 

SEDATIVES. 

Sedatives  (from  sedare,  to  quiet)  are  drugs  employed  for  the 
purpose  of  reducing  irritability  of  the  central  nervous  system. 
They  affect  motor  and  sensory  centers  alike.  In  their  principal 
action,  sedatives  are  closely  related  to  general  anesthetics.  When 
administered  in  therapeutic  doses  they  do  not  produce  anesthetic 
effects;  they  possess  only  mild  anodyne  and  hypnotic  actions. 
Whenever  the  central  nervous  system  becomes  intensely  irritated 
through  external  sources,  or  from  factors  which  originate  ^vithin 
the  body,  general  excitement  results,  which  is  designated  by  the 
general  term  nervousness.  Sedatives  are  indicated  for  these 
disturbances,  and  they  usually  subdue  the  state  of  excitement 
within  a  reasonably  short  time,  while  on  the  healthy  individual 
they  have  apparently  no  effect.  The  most  important  representa- 
tive of  this  therapeutic  group  is  bromin  in  the  form  of  its  alkali 
salts.  It  has  been  experimentally  shown  that  the  bromin  salts  will 
reduce  irritability  of  the  motor  centers  of  the  cerebrum  without 
inducing  anesthesia.  Aside  from  bromin  compounds,  the  ano- 
dynes and  antipyretics  are  often  prescribed  in  milder  cases  of 
nervousness.  A  few  vegetable  and  animal  drugs,  which  are  char- 
acterized by  their  specific,  intense,  and  frequently  disagreeable 
odor — valerian,  asafetida,  castoreum,  etc. — were  in  great  favor  as 
nerve  sedatives  with  the  older  practitioners.  So  far  no  definite 
pharmacologic  action  has  been  attributed  to  these  latter  com- 
pounds. 

Sedatives  frequently  render  valuable  service  in  preparing  a 
hypersensitive  patient  for  a  lengthy  dental  operation.  It  has  been 
clinically  demonstrated  that  the  hypersensitiveness  of  the  teeth, 
which  in  many  cases  is  merely  an  expression  of  a  general  nervous 
irritation  may  be  materially  reduced  by  an  average  dose  of  a  well- 


SEDATIVES  375 

defined  sedative  administered  shortly  before  the  operation  begins. 
Schroder  has  shown  that  15  grains  (1  Gm.)  of  chloral  hydrate  will 
within  ten  minutes  materially  lessen  the  hypersensation  of  exposed 
dentin.  Recently  Hecker^  advocated  bromural  for  the  same  pur- 
pose. The  strain  of  a  lengthy  and  painful  dental  operation  may 
be  much  lessened  by  the  judicious  administration  of  a  sedative, 
which  enables  both  the  patient  and  the  operator  to  save  much  un- 
necessarily expended  nerve  force. 

Potassium  Bromid;  Potash  Bromidum,  U.  S.  P.,  B.  P.;  KBr; 
Bromure  de  Potassium,  F.  ;  Bromkali,  G. 

It  forms  colorless  or  white  crystals,  or  a  granular  powder,  having 
a  strongly  saline  taste.  It  is  soluble  in  1.5  parts  of  water  and  in 
180  parts  of  alcohol. 

Average  Dose. — 15  grains  (1  Gm.). 

Sodium  Bromid;  Sodii  Bromidum,  U.  S.  P.,  B.  P.;  NaBr.  It 
forms  colorless  or  white  crystals,  or  a  granular  powder,  having  a 
saline,  slightly  bitter  taste.  It  is  soluble  in  about  2  parts  of  water 
and  12.5  parts  of  alcohol.    Average  dose,  15  grains  (1  Gm.). 

Ammonium  Bromid;  Ammonii  Bromidum,  U.  S.  P.,  B.  P. ; 
NH^Br.  It  forms  colorless  prismatic  crystals  or  a  white  crystal- 
line powder,  odorless,  and  having  a  pungent,  saline  taste.  It  is 
soluble  in  about  1.5  parts  of  water  and  12.5  parts  of  alcohol.  Aver- 
age dose,  15  grains  (1  Gm.). 

Other  bromids — the  salts  of  lithium,  calcium,  and  strontium, 
hydrobromic  acid,  etc.,  are  used  in  therapeutics;  their  action  de- 
pends principally  on  their  bromin  content.  Bromin  salts  are  best 
prescribed  in  solution,  and  should  be  taken  largely  diluted  with 
water.  The  irritation  resulting  from  the  injection  of  bromin  salts 
into  the  tissues  prohibits  their  application  for  such  purposes. 

Bromural  ;  Alpha-monobrom-isovaleryl-urea  ;  CeHnHgOgBr. 

Bromural  forms  small  white,  almost  tasteless,  needles,  which  are 
readily  soluble  in  hot  water,  but  less  soluble  in  cold  water.  It  is 
a  nerve  sedative,  and  produces  sleep,  with  apparently  no  side 
action  on  the  circulation  or  respiration.  It  is  best  administered  in 
5  grain   (0.3  Gm.)   tablets,  suspended  in  hot  water,  three  times 

»Heckcr:   Dental   Cosmos,   1909,   p.   844. 


376  PHARMACO-THERAPEUTICS 

daily.     To  induce  sleep,  10  grains  (0.6  Gm.)  should  be  taken  at 
bedtime  and  may  be  repeated,  if  needful,  during  the  night. 

Valerian;  Valeriana,  U.  S.  P.;  Valeriana  Radix,  B.  P. 

Valerian  and  its  many  galenic  preparations  have  a  wide  repu- 
tation as  nerve  sedatives.  Nervous  and  hysteric  women  are  espe- 
cially partial  to  their  use. 

Validol.  It  is  the  menthylester  of  valerianic  acid,  containing 
30  per  cent  of  free  menthol.  It  is  a  clear,  colorless  liquid,  having 
a  peculiar  odor  and  a  slightly  bitter  taste.  It  is  insoluble  in  water, 
but  readily  soluble  in  alcohol,  ether,  etc.  It  combines  the  action 
of  valerian  and  menthol,  and  is  used  as  an  analeptic,  antihysteric, 
and  stomachic.  Validol  is  lauded  in  sea  sickness,  and  is  appar- 
ently of  some  value  as  a  prophylactic  in  this  dismal  malady  when 
taken  at  regular  intervals  in  5-drop  doses  mixed  in  a  glass  of 
Bordeaux  wine.    Average  dose,  8  minims  (0.5  C.c). 

CEREBRAL  STIMULANTS. 

Cerebral  stimulants  (from  stimulus,  a  goad)  are  drugs  which 
physiologically  excite  the  motor  centers  of  psychologic  activity. 
They  are  also  known  as  excitants,  or  as  analeptics  (from  analep- 
tikos,  to  restore).  The  latter  term  is  usually  restricted  to  heart 
stimulants.  In  the  excitement  caused  by  artificial  stimulation, 
other  cerebral  centers  are  also  involved — as  the  respiration,  the 
heart,  the  vasomotor  centers,  etc.  It  may  be  observed,  however, 
that  general  excitement,  which  manifests  itself  in  an  increased 
physical  activity,  garrulity,  etc.,  is  not  always  the  result  of  cerebral 
stimulation;  often  the  reverse  is  the  case — that  is,  a  paralysis  of 
the  higher  inhibiting  centers. 

Caffein  is  the  most  pronounced  representative  of  the  cerebral 
stimulants;  it  causes  physical  excitement  without  being  followed 
by  depression.  Cocain  (See  Local  Anesthetics),  in  its  pure  form 
or  as  the  coca  leaf,  is  freely  used  as  a  cerebral  stimulant  by  the 
Indians  of  Bolivia  and  Peru,  and  by  the  negroes  of  the  United 
States.  On  account  of  its  poisonous  nature  it  is  not  employed 
medicinally  for  these  purposes.  Certain  substances,  as  strychnin, 
etc.,  increase  the  irritability  of  the  centers  of  reflex  stimulation  to 
a  marked  degree,  while  other  alkaloids  have  a  special  predilection 


CEREBRAL   STIMULANTS  377 

for  the  tetanic  centers  in  the  brain  and  in  the  spinal  cord.  Alcohol, 
in  its  many  modifications  and  administered  in  small  doses,  is  a 
cerebral  stimulant  of  importance,  although  many  pharmacologists 
deny  this  characteristic  effect,  claiming  that  alcohol  is  a  narcotic. 
In  the  hands  of  the  clinician,  however,  alcohol  in  small  doses 
proves  to  be  a  valuable  stimulant,  which  is  extensively  used.  The 
respiratory  centers,  the  vasomotor  center,  and  the  heart  may  be 
easily  excited  by  direct  stimulation  or  by  reflex  action — as  by  the 
inhalation  of  ammonia  vapors,  faradic  stimulation,  slapping  with 
wet  towels,  etc.  Cerebral  stimulants  are  indicated  in  fainting,  in 
exhausting  chronic  diseases,  in  poisoning  by  anesthetics,  etc. 

Strong  infusions  of  coffee  and  tea  are  well-known  cerebral 
stimulants ;  they  do  not  contain  nutritious  substances.  For  a  short 
time  they  may  depress  the  feeling  of  hunger  and  increase  mental 
and  physical  activity,  which  is  often  followed  by  a  slightly  in- 
creased appetite.  In  some  respects  large  doses  of  caffein  (coffee 
or  tea)  act  antagonistic  to  those  of  alcohol;  strong  coffee  and  tea 
increase  the  mental  faculties,  and  are  often  productive  of  insomnia, 
especially  in  nervous  individuals,  while  large  doses  of  alcohol 
stupefy  and  rather  invite  sleep. 

Alcohol  (see  Antiseptics  of  the  Marsh  Gas  Series)  as  a  cerebral 
stimulant  is  principally  employed  in  the  form  of  fermented  liquors 
and  wines,  containing  from  3  to  70  per  cent  of  pure  ethyl  alcohol. 
Alcohol  in  concentration  of  65  per  cent  or  more  precipitates  al- 
bumin, and  acts  as  a  caustic.  The  mucous  membranes  of  the  mouth 
and  throat  of  those  who  are  used  to  strong  alcoholic  drinks  are 
not  much  affected  by  liquors  containing  50  to  65  per  cent  of 
pure  alcohol  (rum,  arrack,  etc.),  while  the  unaccustomed  suffer 
with  a  feeling  of  burning  and  coughing  after  their  use.  The  opin- 
ions regarding  the  use  of  fermented  liquors  as  cerebral  stimulants 
differ  widely ;  it  is  impossible  to  definitely  outline  when  alcohol  is 
indicated  for  such  purposes.  The  general  consensus  of  opinions 
of  experienced  clinicians  points  to  the  fact  that  alcohol  admin- 
istered in  rational  doses  seemingly  reduces  the  excitability  of  the 
patient  caused  by  external  or  internal  irritation.  In  certain 
infectious  diseases — septicemia,  pyemia,  etc. — ^the  administration 
of  alcohol  in  large  quantities  is  apparently  useful  as  a  means  of 
increasing  the  resistance  of  the  body  against  the  inviting  foe  by 
probably    favorably    influencing    the    formation    of    antitoxins. 


378  PHARMACO-THERAPEUTICS 

Again,  alcohol  in  the  form  of  whisky  is  lauded  as  a  stimulant  of 
the  circulation,  especially  the  heart;  its  usefulness  under  these 
conditions  is  referred  to  under  Circulatory  Stimulants.  Whether 
alcohol  is  a  nutrient  in  the  true  sense  of  the  word  is  as  yet  not  fully 
proved ;  it  is  certain,  however,  that  it  inhibits  the  rapid  disintegra- 
tion of  the  albuminous  contents  of  the  cells,  especially  in  lasting 
febrile  diseases,  and  thereby  acts  as  an  indirect  means  of  saving 
valuable  bodily  strength.  Incidentally,  it  is  often  employed  as  a 
vehicle  in  the  administration  of  nutritious  substances — yolk  of 
egg  in  the  well-known  form  of  egg-nog.  The  habitual  use  of 
liquors  containing  over  30  per  cent  of  alcohol,  especially  when 
taken  into  the  empty  stomach,  causes  chronic  disturbances  of  the 
latter,  which  manifest  themselves  in  catarrh,  vomitus,  etc. 

Caffein;  Caffeina,  U.  S.  P.,  B.  P.;  CgHioN.O^+HaO ; 

CaFEINE,    F.  ;    KOFFEIN,    G. 

Caffein  is  a  feeble  basic  substance  obtained  from  the  dried  seed 
of  coffee,  Coffea  arahica,  or  the  dried  leaves  of  tea,  Thea  sinensis. 
It  appears  in  long  white,  silky  crystals,  odorless,  but  having  a  bit- 
ter taste.  It  is  soluble  in  about  46  parts  of  water,  45  parts  of 
alcohol,  and  readily  soluble  in  boiling  water. 

Average  Dose. — 1  grain  (0.065  Gm.). 

Citrated  Caffein;  Caffeina  Citrata,  U.  S.  P.;  Caffeinm  Citras, 
B.  P.  It  is  a  white  powder,  consisting  of  a  weak  chemic  combina- 
tion of  citric  acid  with  caffein.  It  is  soluble  in  about  25  parts  of 
water.    Average  dose,  2  grains  (0,125  Gm.). 

Effervescent  Citrated  Caffein;  Caffeina  Citrata  Effervescens,  U. 
S.  P. ;  Caffeinm  Citras  Effervescens,  B.  P.  An  effervescent  powder, 
consisting  of  a  mixture  of  citrated  caffein  with  sodium  bicarbonate, 
tartaric  acid,  and  sugar.     Average  dose,  60  grains  (4  Gm.). 

Whisky  ;  Spiritus  Frumenti,  U.  S.  P. ;  Eau  de  Vie  de  Granis, 
F. ;  Kornbranntwein,  G. 

An  alcoholic  liquid  obtained  by  the  distillation  of  the  mash  of 
fermented  grain — as  Indian  corn,  rye,  wheat,  barley,  etc.  It  is 
an  amber-colored  fluid,  having  a  distinctive  odor  and  taste,  and 
should  contain  from  44  to  55  per  cent  by  volume  of  absolute  al- 
cohol. 


STOMACHICS    AND   DIGESTIVES 


379 


Brandy;  Spiritus  Vini  Gallici,  U.  S.  P.,  B.  P.;  Brandy;  Cog- 
nac, F. ;  Franzbranntwein,  G. 

An  alcoholic  liquid  obtained  by  the  distillation  of  the  fermented 
unmodified  juice  of  fresh  grapes.  It  is  a  pale,  amber-colored  fluid, 
having  a  distinctive  odor  and  taste,  and  should  contain  from  46  to 
55  per  cent  by  volume  of  absolute  alcohol. 

White  Wine  ;  Vinum  Album,  U.  S.  P. ;  Vin  Blanc,  F.  ; 
Weisswein,  G. 

It  is  the  fermented  juice  of  fresh  grapes,  and  should  contain 
from  8  to  15  per  cent  by  volume  of  absolute  alcohol. 

Bed  Wine  ;  Vinum  Rubrum,  U.  S.  P. ;  Vin  Rouge,  F.  ; 
Rotwein,  G. 

It  is  the  fermented  juice  of  fresh  red-colored  grapes,  and  should 
contain  from  8  to  15  per  cent  by  volume  of  absolute  alcohol. 

The  following  table  gives  the  list  of  the  average  alcoholic  com- 
ponent of  the  more  important  fermented  liquors. 

ALCOHOLIC  COMPONENT  OF  THE  MOKE  IMPORTANT  ALCOHOLIC  BEVERAGES. 


Per  cent  by  volume. 

Lager  beer 2  to  3.5  per  cent. 

Export  beer 3.5  to  4.3  per  cent. 

Ale,  porter,  stout      3  to  6  per  cent. 

Moselle  wine....      7  to  8  per  cent. 

Rhine    wine 8  to  9  per  cent. 

French  red  wine.    7.5  to  U  per  cent. 

Claret    8  to  14  per  cent. 

Catawba  10  to  12  per  cent. 

Sherry 14  to  18  per  cent. 


r^er  cent  by  volume. 

Port 15  to  19  per  cent. 

Champagne,  dry..  10  to  11  per  cent. 

Champagne,  sweet  9  to  10  per  cent. 

Cider 5  to  10  per  cent. 

German  schnapps.  38  to  42  per  cent. 

Whisky 44  to  55  per  cent. 

Brandy  46  to  55  per  cent. 

Gin    45  to  50  per  cent. 

Rum    50  to  70  per  cent. 


STOMACHICS  AND  DIGESTIVES. 

Stomachics  (from  stomacJium,  stomach)  and  digestives  (from 
digere,  to  digest)  form  one  of  the  many  groups  in  pharmaco- 
therapeutics  which  can  not  be  precisely  defined.  The  remedies  of 
this  group  perform  certain  functions  which  beneficially  influence 
the  many  duties  of  the  stomach.  The  stomach  has  to  fulfill  a 
motor  function — that  is,  its  rhythmic  peristaltic  movements  mixes 
the  ingested  foodstuffs  with  its  own  secretions  and  then  passes 
the  liquefied  material  through  the  pylorus  into  the  small  intestines. 


380  PHARMACO-THERAPEUTICS 

The  stomach  secretes  the  gastric  juice,  consisting  of  pepsin, 
rennin,  hydrochloric  acid,  inorganic  salts,  and  water.  The  hydro- 
chloric acid  disintegrates  the  albumins  and  muscle  fibers,  and  pre- 
pares them  for  the  action  of  the  pepsin.  The  latter  dissolves  the 
albumin  and  changes  the  albuminates  into  proteoses  and  peptons. 
The  rennin  precipitates  casein  from  the  milk  which  has  been  taken 
into  the  stomach;  the  casein  is  dissolved  by  the  proteolytic  action 
of  the  pepsin.  The  stomach  wall  absorbs  only  very  few  dissolved 
substances.  Water  or  aqueous  solutions,  even  if  they  contain 
easily  diffusible  substances,  are  not  absorbed,  while  alcohol,  alco- 
holic solutions,  and  volatile  substances  are  more  readily  absorbed. 
The  hydrochloric  acid  component  (0.2  per  cent)  of  the  gastric 
juice  has  to  perform  another  important  function;  it  acts  as  a 
sterilizing  medium  of  the  contents  of  the  stomach.  Many  of  the 
swallowed  bacteria,  especially  pathogenic  germs,  are  promptly  de- 
stroyed by  this  acid.  The  mucous  memj)rane  of  the  stomach  may 
become  anatomically  altered,  and  many  diseases — catarrh,  ulcer, 
hemorrhage,  etc. — may  result,  which  incidentally  lessen  or  inhibit 
its  function. 

One  or  all  of  the  enumerated  functions  of  the  stomach  may  be- 
come disturbed,  and  it  is  then  the  duty  of  the  physician  to  read- 
just the  disturbed  faculties.  Antiseptics  are  occasionally  neces- 
sary to  inhibit  abnormal  fermentation.  Diluted  hydrochloric  acid, 
boric  acid,  or  resorcinol  in  1  per  cent  solution  are  indicated.  The 
latter  two  are  especially  useful  when  employed  as  lavage.  Belch- 
ing, which  is  caused  by  the  presence  of  fatty  acids  as  a  result  of 
abnormal  fermentation,  may  be  greatly  relieved  by  mild  antiseptics. 
Astringents  are  indicated  to  protect  inflamed  mucous  surfaces, 
especially  in  ulcers  of  the  stomach.  Bismuth  subnitrate  alone  or 
in  combination  with  magnesia  (milk  of  magnesia)  is  serviceable 
for  such  purposes.  Pronounced  astringent  action  is  readily  ob- 
tained with  lavage  of  silver  nitrate  solution,  1 :1,000.  Acute  or 
chronic  catarrh  is  beneficially  influenced  by  the  neutral  salts 
(sodium  chlorid,  etc.).  Overproduction  of  hydrochloric  acid  in 
the  stomach  can  be  correctly  determined  only  by  a  chemic  analysis 
of  a  test  meal.  It  calls  for  mild  antacids — sodium  bicarbonate, 
calcined  magnesia,  and  milk  of  magnesia.  The  latter  preparation 
is  preferably  employed,  as  it  incidentally  neutralizes  carbonic  acid, 
which  otherwise  unnecessarily  distends  the  stomach.     If  there  is 


STOMACHICS   AND   DIGESTIVES  381 

an  insufficiency  of  hydrochloric  acid,  it  is  readily  supplied  by  ad- 
ministering the  well-diluted  acid.  The  latter  is  preferably  given 
either  before  meals  to  increase  the  appetite,  or  after  meals  to 
promote  digestion.  By  reflex  action  the  secretion  of  hydrochloric 
acid  may  be  artificially  increased ;  the  simple  bitters — as  gentian, 
columbo,  dandelion,  etc. — are  administered  for  such  purposes. 
The  ferments  present  in  the  gastric  juice — pepsin  and  rennin — 
may  also  be  artificially  substituted  in  case  of  need.  Pepsin,  prefer- 
ably in  the  form  of  its  many  solutions,  or  its  vegetable  substitute, 
papain,  is  indicated  for  the  purpose.  The  various  combined  func- 
tions of  the  stomach  may  be  increased  in  their  total  action  by  re- 
flex stimulation.  The  simple  bitters  known  as  stomachics,  di- 
gestives, aromatics,  and  by  other  titles,  diluted  alcohol  in  the  form 
of  wine  or  beer,  and  carbonated  table  waters  are  valuable  reflex 
stimulants.  The  common  habit  of  having  table  waters,  wines,  etc., 
"iced,"  especially  when  taken  into  the  empty  stomach,  and  too 
fast  eating  are  largely  responsible  for  the  many  forms  of  stomach 
diseases  which  are  generically  referred  to  as  dyspepsia. 

Gentian  ;  Gentiana,  U.  S.  P. ;  Gentians  Radix,  B.  P. ;  Gentiane 
Jaune,  F.  ;  Enzian,  G. 

It  is  the  root  of  Gentiana  lutea;  it  contains  a  glucosid,  gen- 
tiopicrin,  a  trace  of  tannic  acid,  and  other  bodies  of  less  impor- 
tance. In  the  form  of  an  extract,  fluidextract,  or  tincture  it  is 
widely  used  as  a  bitter  tonic. 

Average  Dose. — 15  grains  (1  Gm.). 

Columbo;  Calumba,  U.  S.  P.;  Calumb^  Radix,  B.  P.; 
Columbo,  F.  ;  Columbowurzel,  G. 

It  is  the  root  of  JateorMza  palmata;  it  contains  columbin  and 
columbinic  acid,  and  is  principally  employed  in  the  form  of  an 
extract,  fluidextract,  tincture,  or  infusion.  It  is  used  as  a  tonic, 
stomachic,  and  mild  astringent. 

Average  Dose. — 30  grains  (2  Gm.). 

Dandelion  ;  Taraxacum,  U.  S.  P. ;  Taraxaci  Radix,  B.  P. ; 
Lion  's  Tooth  ;  Dent  de  lion,  F.  ;  Lowenzahn,  G. 

It  is  the  root  of  dandelion,  Taraxacum  officinale,  and  contains 
two  neutral  bitter  substances.     It  is  principally  employed  in  the 


382  PHARMACO-THERAPEUTICS 

form  of  an  extract,  fluidextract,  tincture,  or  the  expressed  juice. 
It  is  used  as  a  bitter  tonic  and  stomachic. 

Average  Dose. — 120  grains  (8  Gm.). 

Quassia  ;  Quassia,  U.  S.  P. ;  Quassia  Lignum,  B.  P. ;  Bitter 
Ash;  Bitter  Wood;  Quassie,  F. ;  Quassienholz,  G. 

It  is  the  wood  of  Picrasma  excelsa,  and  contains  several  bitter 
substances  which  resemble  each  other  closely  and  are  known  as 
quassins.  In  the  form  of  an  extract,  tincture,  or  infusion  it  is 
used  as  a  bitter  tonic  and  febrifuge. 

Average  Dose. — 7i/^  grains  (0.5  Gm.). 

Serpentaria;  Serpentaria,  U.  S.  P.;  Serpentari^  Rhizoma,  B. 
P.;  Virginia  Snake  Root;  Couleuvree  de  Virgine,  F. ;  Vir- 
ginianische  Schlangenwurzel,  G. 

It  is  the  rhizome  and  wood  of  Aristolocliia  reticulata,  and  con- 
tains a  volatile  oil,  a  bitter  principle,  and  an  alkaloid,  aristolochin. 
It  is  usually  employed  in  the  form  of  a  fluidextract,  tincture,  or 
infusion. 

Average  Dose. — 15  grains  (1  Gm.). 

Hops;  Humulus,  U.  S.  P.;  Lupulus,  B.  P.;  Houblon,  F. ; 

Hopfen,  G. 

They  are  the  dried  strobiles  of  Humulus  lupulus,  and  contain  a 
volatile  oil,  a  bitter,  neutral  substance,  lupulin,  and  resins.  Hops 
are  employed  in  the  form  of  a  fluidextract,  oleo-resin,  tincture,  or 
infusion,  and  are  used  as  a  tonic,  carminative,  diuretic,  and  exter- 
nally in  the  form  of  a  poultice  as  an  anodyne  and  hypnotic. 

Average  Dose. — 30  grains  (2  Gm.). 

Orexin  Hydroclilorid.  It  is  a  yellowish-white  crystalline  pow- 
der, soluble  in  15  parts  of  water,  with  a  bitter  taste.  It  is  prin- 
cipally administered  in  the  form  of  a  powder,  or  as  tablets  as  an 
appetizer  and  an  antiemetic.     Average  dose,  5  grains   (0.3  Gm.). 

Pepsin;  Pepsinum,  U.  S.  P.,  B.  P.;  Pepsine,  F.  ;  Pepsin,  G. 

It  is  a  proteolytic  ferment  obtained  from  the  glandular  layers 
of  the  fresh  stomach  of  the  healthy  hog,  and  capable  of  digesting 
not  less  than  3,000  times  its  o\vti  weight  of  freshly  coagulated 
albumin.     It  is  a  white  or  cream-colored  amorphous    powder,    or 


EMETICS  383 

thin,  yellowish,  translucent  scales,  free  from  any  offensive  odor, 
and  having  a  slightly  acid  or  saline  taste.  It  is  soluble  in  about 
50  parts  of  water,  and  its  solubility  is  increased  if  the  water  is 
slightly  acidulated  with  hydrochloric  acid.  Pepsin  is  usually 
administered  during  or  after  meals. 

Average  Dose. — 4  grains  (0.25  Gm.). 

Papain;  Papayotin;  Papoid;  Vegetable  Pepsin.  It  is  the  con- 
centrated, active  principle  of  the  juice  of  the  fruit  and  leaves  of 
the  papaw,  Carica  papaya.  It  is  a  whitish  hygroscopic  powder, 
soluble  in  water  and  glycerin,  and  is  used  as  a  substitute  for  pep- 
sin.   Average  dose,  4  grains  (0.25  Gm.). 

Pepsin  and  its  substitute,  papain,  have  been  advocated  as  a 
means  of  digesting  the  dead  dental  pulp.  Oakley  Coles,  Arkovy, 
and  Harlan  have  recommended  it  for  such  purposes;  it  is  rarelj' 
employed  at  present. 

Pancreatin  ;  Pancreatinum,  U.  S.  p.  ;  Pancreatine  Medicinale, 
F. ;  Pancreatin,  G. 

It  is  a  mixture  of  enzymes  which  exist  in  the  pancreas  of  warm- 
blooded animals,  and  is  usually  obtained  from  the  fresh  pancreas 
of  the  pig.  It  forms  a  yellowish  or  grayish-white  amorphous  pow- 
der, having  a  faint  odor  and  a  meat-like  taste.  It  is  slowly  soluble 
in  water,  but  insoluble  in  alcohol.  It  is  given  in  powder,  or  in 
very  weak  acid  or  alkaline  solution;  it  should  never  be  given  in 
combination  with  pepsin.  Pancreatin  digests  albuminoids  and 
converts  starch  into  sugar,  dextrin,  or  maltose. 

Average  Dose. — 7I/2  grains  (0.05  Gm.). 

Pepsin  Paste. 

B     Pepsin.  gr.  xv   (1.0  Gm.) 

Acid,  hydrochloric,  dil.  gtt.  iv   (0.25  C.c.) 

AqujE  destil.  q.  s.  to  make  a  stiff  paste. 

This  paste  is  packed  into  the  pulp  chamber  in  close  con- 
tact with  the  dead  pulp;  it  is  sealed  in  and  left  undisturbed 
for  a  week.    It  will  digest  (liquefy)  the  dead  pulp. 

EMETICS. 

Emetics  (to  vomit)  are  remedies  which  cause  forcible  expulsion 
of  the  contents  of  the  stomach  through  the  esophagus.    They  were 


384  PHARMACO-THERAPEUTICS 

much  more  frequently  employed  in  former  years  than  at  present. 
Vomiting  is  a  localized  process;  it  is  artificially,  sometimes  spon- 
taneously, produced  to  relieve  an  overfilled  stomach  or  to  remove 
poison.  The  use  of  the  stomach  tube  has  greatly  lessened  the  sys- 
tematic administration  of  emetics  of  bygone  days,  and  the  tube 
should  be  employed  whenever  possible.  Vomiting  is  partially  a 
physiologic  process ;  it  occurs  very  frequently  and  without  further 
disturbances  in  infants  and  young  children.  The  older  we  get,  the 
less  often  we  vomit,  and  the  more  we  suffer  from  the  accompany- 
ing disagreeable  side  effects.  In  the  ruminants  rechewing  of  the 
cud  is  a  physiologic  process,  which  is  performed  by  these  animals 
with  apparently  much  pleasure.  Many  birds — eagle,  hawk,  owl, 
crow,  etc. — and  many  fishes — carp,  pike,  barbel,  etc. — vomit  the 
balled-up  undigestible  material  after  their  meals,  while  the  rodents 
never  vomit.  The  physiologic  act  of  vomiting  is  produced  by  an 
irritation  of  the  vomiting  centers  in  the  fourth  ventricle.  The 
irritation  is  carried  to  these  centers  from  the  periphery — the 
mucous  coat  of  the  stomach  and  other  organs  of  the  abdominal 
cavity.  The  act  of  vomiting  consists  in  a  series  of  definite 
processes;  a  strong,  positive  pressure  is  brought  on  the  abdomen, 
which  contracts  the  abdominal  muscles,  and  causes  a  negative 
pressure  of  the  thoracic  cavity.  Incidentally  the  cardiac  end  of 
the  stomach  is  opened,  and  its  contents  are  suddenly  forced  into 
the  esophagus.  The  muscles  of  respiration  will  also  contract,  and 
the  resulting  positive  pressure  forces  the  food  from  the  esophagus 
into  the  mouth.  During  the  process  of  vomiting  large  quantities 
of  saliva  and  mucus  are  secreted  by  the  glands  of  the  mouth, 
pharynx,  and  esophagus,  and  probably  also  by  those  of  the  larynx. 
Vomiting  always  depresses  the  circulation.  The  preliminary 
psychic  stage  of  vomiting  is  accomplished  in  man  by  an  intensely 
disagreeable,  sickening  feeling  known  as  nausea.  The  thought  of 
certain  food  or  of  loathsome  things,  or  even  listening  to  stories 
which  are  nauseating,  may  produce  this  feeling  of  intense  disgust. 
Emetics  act  by  reflex  action  or  by  direct  stimulation.  By  reflex 
action — irritation  of  the  pharynx,  the  stomach,  the  intestines,  the 
uterus,  etc. — ^vomiting  is  easily  produced.  The  direct  stimulation 
of  the  centers  of  vomiting  may  result  from  anemia  of  the  brain, 
pressure  on  the  brain,  and  from  chemic  substances.  The  metallic 
salts  and  ipecac  produce  only  reflex  action,  they  have  to  be  in- 


EMETICS  385, 

gested  into  the  stomach  to  create  vomiting,  and  will  not  act  when 
injected  hypodermieally  or  subcutaneously.  Apomorphin  acts  by 
direct  stimulation  of  the  vomiting  centers,  and  produces  much 
prompter  results  when  injected  hypodermieally. 

Emetics  are  indicated  to  remove  foreign  bodies  from  the 
esophagus  or  the  stomach.  If  a  foreign  body  has  lodged  in  the 
trachea  and  is  not  removed  by  a  coughing  spell,  pressure  produced 
by  spasmodic  vomiting  may  occasionally  be  helpful  in  its  dis- 
lodgement.  This  procedure  may  be  of  some  service  in  case  a  tooth 
has  fallen  into  the  upper  trachea  during  its  extraction.  Poisons 
which  have  entered  the  stomach  should  be  removed  as  quickly  as 
possible  to  prevent  absorption.  While  lavage  of  the  stomach  with 
the  stomach  tube  is  the  correct  procedure  for  such  treatment, 
emetics  are  often  of  great  assistance.  Occasionally  an  overloaded 
stomach  needs  the  quick  removal  of  its  contents.  As  Livy  tells 
us,  the  peacock  feather  was  used  for  such  purposes  by  the  Roman 
slaves,  especially  during  the  reign  of  the  emperors,  to  tickle  the 
pharynx  of  their  masters  after  a  lucullic  feast.  Emetics  are  also 
of  some  service  in  aiding  the  therapeutic  action  of  expectorants. 
The  false  membranes  of  croup  may  be  forcibly  removed  by  induc- 
ing vomiting,  which  incidentally  produces  a  helpful  increased 
secretion  of  the  mucous  membrane  of  the  pharynx  and  larynx, 
and  probably  of  the  upper  bronchi.  Emetics  are  counterindicated 
in  aneurysms,  in  pulmonary  tuberculosis,  in  the  senile,  and  in  the 
last  stages  of  pregnancy. 

Antimony  and  Potassium  Tartrate;  Antimonii  et  Potassii 
Tartras,  U.  S.  p.  ;  Antimonium  Tartaratum,  B.  P. ;  Tartar 
Emetic;  Tartre  Stibie,  F. ;  Brechweinstein,  G. 

It  forms  colorless,  transparent  crystals,  or  a  white  granular 
powder,  without  odor,  and  having  a  sweetish  and  afterward  dis- 
agreeable metallic  taste.  It  is  soluble  in  17  parts  of  cold  water  and 
insoluble  in  alcohol. 

Average  Dose. — 1/2  grain  (0.03  Gm.). 

Wine  of  Antimony;  Vinum  Antimonii,  U.  S.  P.,  B.  P.  Four 
parts  tartar  emetic  dissolved  in  1,000  (875,  B.  P.)  parts  of  white 
wine.    Average  dose,  15  minims  (1  C.c). 

Copper  SulpJiate;  Cupri  Sulphas,  U.  S.  P.,  B.  P.    As  an  emetic 


386  PHARMACO-THERAPEUTICS 

it  is  given  in  2  to  4-grain  (0.13  to  0.25  Gm.)  doses,  dissolved  in 
a  glass  of  water. 

Zinc  Siilpliate;  Zinci  Sulplias,  U.  S.  P.,  B.  P.  As  an  emetic 
it  is  given  in  15  grain  (1  Gm.)  doses,  dissolved  in  a  glass  of  water. 

Mercury  Subsulphate;  Hydrargyri  Subsulphas  Flavus; 
TuRPETH  Mineral. 

A  heavy  lemon-yellow  powder,  odorless  and  almost  tasteless.  It 
is  only  partially  soluble  in  water. 

Average  Dose. — 2  grains  (0,13  Gm.)  stirred  in  water. 

Apomorphin  Hydrochlorid  ;   Apomorphin^  Hydrochloridum, 
U.  S.  P.,  B.  P.;  Ci,H,,NO,.HCl. 

It  is  the  grayish-white  crystalline  hydrochloric  salt  of  an  arti- 
ficially prepared  alkaloid  from  morphin,  odorless,  and  having  a 
slightly  bitter  taste.  It  is  very  soluble  in  water,  turning  green 
or  even  black  when  kept  in  solution. 

Average  Dose. — Yiq  grain  (0.005  Gm.)   hypodermically. 

Ipecac;  Ipecacuanha,  U.  S.  P.,  B.  P.;  Racine  Bresilienne,  F. ; 

Brechwurzel,  G. 

It  is  dried  root  of  Caceplicelis  ipecacuanlia.  The  powdered  root, 
stirred  in  water,  is  used  as  an  emetic. 

Average  Dose. — 15  grains  (1  Gm.), 

The  chief  alkaloids  of  ipecac  are  emetin,  cephaelin  and  psycho- 
toin.  Emetin  acts  similarly  to  ipecac,  but  it  is  relatively  less  emetic, 
while  cephaelin  is  more  emetic  and  less  nauseant. 

Emetin  Hydrochlorid  ;  Emetine  Hydrochloridum,  U,  S.  P, 

A  white,  crystalline  powder,  having  a  bitter  taste;  soluble  in 
water  and  alcohol.  Average  dose. — i/^  grain  (0.03  Gm.)  by  hypo- 
dermic injection  as  an  emetic  and  in  Y2  P^r  cent  solution  (in  phy- 
siologic salt  solution)  dropped  into  the  pockets  for  the  treatment 
of  pyorrhea  alveolaris. 

Syrup  and  wine  of  ipecac  are  also  used  as  emetics. 

In  cases  of  emergency  a  tablespoonful  of  powdered  mustard 
stirred  in  a  cupful  of  warm  water,  a  teaspoonful  of  salt  dissolved 
in  a  glass  of  hot  water,  a  few  grains  of  alum  dissolved  in  a  glass  of 
water,  or  hot  water  alone  may  be  tried.     They  all  irritate,  more 


EMETICS  387 

or  less,  the  mucous  lining  of  the  stomach  (except  the  hot  water, 
which  produces  nausea)  and  they  act  then  as  emetics. 

In  June,  1914,  Dr.  M.  T.  Barrett  and  Prof.  Allen  J.  Smith,  of 
the  University  of  Pennsylvania,  announced  the  discovery  of  the 
endameha  huccalis  in  the  pus  exudate  from  "forty-six  cases  of 
suppurative  affection  of  the  gums  and  pericemental  tissue."^  In 
all  of  these  cases  without  a  single  exception  the  above  organism  was 
found  to  be  present  and  from  these  findings  they  suggested  the 
probable  etiologic  relationship  of  the  endameba  buccalis  to  pyor- 
rhea alveolaris.  Incidentally,  the  authors  recommend  the  use  of 
emetin  hydrochlorid  as  a  remedial  agent  for  the  eradication  of 
this  disease.  In  September  of  the  same  year  the  Dental  Cosmos 
published  a  paper  on  the  same  subject  by  Prof.  Chiavaro,^  of 
Rome,  read  by  him  in  Paris  in  July,  1914.  In  September,  1914, 
Bass  and  Johns,^  of  New  Orleans,  published  their  "Independent 
Discovery"  of  essentially  the  same  findings  as  those  made  by  Bar- 
rett and  Smith. 

Pyorrhea  alveolaris  is  a  polymorphic  disease,  producing  its 
manifestations  primarily  locally  and  it  may  be  caused  by  many 
etiologic  factors.  For  convenience  sake  we  may  define  pyorrhea  as 
the  expression  of  an  ensemble  of  prodromal  signs,  i.e.,  a  chronic, 
purulent  inflammation  of  the  pericementum  with  progressive  ne- 
crosis of  the  alveolar  bone  and  loosening  of  the  teeth  within  the  af- 
fected region.  The  causative  factors  of  the  disease  may  be  classi- 
fied as  (1)  predisposing  causes,  (2)  local  disturbances,  and  (3) 
bacterial  infection  of  a  mixed  type.  An  indirect  lowering  of  the 
tonicity  of  the  involved  tissues  is  always  present.  As  a  sequence, 
the  eradication  of  this  disease  depends  on  the  elimination  of  all 
the  etiologic  factors,  and,  consequently,  the  treatment,  of  neces- 
sity, must  be  a  combination  of  surgical,  medicinal  (including  bio- 
logic), and  mechanical  procedures. 

Emetin  is  a  genuine  specific  etiotropic  remedy,  i.  e.,  it  is  a  drug 
which  acts  directly  on  the  causative  agent  of  a  disease.  If  py- 
orrhea were  solely  caused  by  the  endameba,  emetin  should  be  a 
true  specific  for  this  much  dreaded  malady.  Clinical  experience 
has  not  borne  out  the  early  hopes  which  were  placed  in  this  drug. 
Nevertheless,  emetin  is  an  important  adjunct    in    the    medicinal 


»  Barrett:  Dental  Cosmos,  1914,  pp.  948  and  1345. 

'Chiavaro:  Dental  Cosmos,  1914,  p.   1089. 

•Bass  and  Johns:  Alveolo-Dental  Pyorrhea,  Philadelphia,  1915. 


388  PHARMACO-THERAPEUTICS 

care  of  the  pus  pockets  and  deserves  a  prominent  place  in  the  arma- 
mentarium of  the  dentist.  Its  local  application  should  constitute  a 
part  of  the  routine  procedure  in  the  treatment  of  pyorrhea.  In 
applying  emetin,  only  the  purest  alkaloid  obtainable  must  be  em- 
ployed, as  grave  symptoms  of  intoxication  or  even  death  from 
rather  small  doses  may  occur,  "The  products  supplied  as  emetin 
hydrochlorid  are  variable  in  composition  and  in  toxicity  to  a  de- 
gree which  constitutes  a  serious  danger."^  Extreme  care  should 
be  exercised  not  to  get  any  of  the  emetin  into  the  eyes.  The  ac- 
cident is  usually  followed  by  a  severe  reaction.  There  is  no  pain 
at  first,  but  in  about  eight  hours  there  is  an  uncomfortable, 
scratchy  feeling  accompanied  by  conjunctival  and  circumcorneal 
injection  which  may  last  for  two  or  three  days. 

Barrett  and  Smith,  in  their  various  publications,  have  suggested 
the  following  procedures  for  the  identification  of  the  endamebas  and 
their  treatment  with  emetin : 

Mode  op  Application  of  Emetin  Hydrochlorid. — The  remedy,  in  the  opin- 
ion of  the  writer,  for  pyorrhea  alone  is  best  administered  by  local  application 
to  foci  of  suppuration  about  the  teeth.  Where  there  is  a  wider  distribution  of 
the  parasites,  as  in  the  tonsils  or  elsewhere,  and  where  systemic  complications 
exist,  the  hj-podermic  administration  of  the  remedy  is  to  be  advised.  Pyorrhea 
may  likewise  be  dealt  with  by  hypodermic  or  intramuscular  administration  of 
emetin,  a  procedure  especially  commended  by  Bass  and  Johns.  A  %  per  cent 
solution  of  emetin  hydrochlorid  is  effective  and  preferable  in  local  treatments, 
higher  concentrations  being  likely  to  provoke  inflammatory  reactions  in  the 
gum.  Care  should  be  exercised  to  use  a  neutral  solution  of  the  salt,  as  free 
hydrochloric  acid  is  apt  to  be  an  irritant  to  the  gums  and  adjacent  surfaces. 
The  simple  litmus  test  is  sufficient  to  determine  this  point,  and  all  new  solu- 
tions should  be  tested,  and  if  necessary  neutralized  by  the  addition  of  a  suit- 
able amount  of  sodium  carbonate.  The  solution  is  introduced  in  the  pyorrhea 
pockets  with  an  ordinary  hj'podermic  syringe  with  a  straight  or  curved  needle 
as  needed,  so  as  to  gain  access  to  all  parts  of  the  pockets.  The  point  of  the 
needle  should  pass  along  the  root  of  the  tooth  to  the  bottom  of  the  pocket, 
merely  engaging  with  the  wall,  and  be  carried  about  to  all  of  its  parts.  In 
one  sense,  of  course,  it  would  be  well  to  actually  penetrate  the  wall  of  the 
pocket,  and  thus  in  the  discharge  of  the  solution  insure  diffusion  of  the  emetin 
in  the  surrounding  tissues.  However,  this  is  not  essential,  and  the  mechanical 
harm  done  to  the  wall  by  the  instrument  puncture,  and  that  occasioned  by  car- 
rying infective  material  through  the  wall  by  the  penetrating  point,  are  suffi- 
cient reasons  for  trying  to  avoid  such  strenuous  and  unnecessary  efforts.  Un- 
questionably, bothersome  local  inflammation  can  be  occasioned  by  failure  to 
avoid  this  source  of  irritation.     Each  pocket  in  turn  is  thus  filled  with  the 


*  Journal  American  Medical  Association,  Ixvi,  p.   1310. 


EMETICS 


389 


emetin  hydrochlorid  solution;  and  the  writer  believes  it  to  be  good  practice 
to  apply  the  solution  also  to  parts  which  according  to  gross  examination  are 
not  involved — as  into  the  interdental  spaces  and  around  fixed  appliances. 
Treatments  which  thus  include  all  recognizable  pockets  and  special  parts  un- 
der suspicion  should  be  repeated  daily  for  at  least  five  days,  and  thereafter 
every  other  day  until  about  ten  treatments  as  a  total  have  been  made,  as  a 
general  rule.  Microscopic  examination  of  scrapings  from  the  pockets  should 
be  made  from  time  to  time  for  persisting  endamcebaj  as  the  treatment  pro- 
gresses, and  this,  together  with  the  general  appearance  of  the  lesions,  will 
determine  the  appropriate  duration  of  the  period  of  treatment.  In  some  of 
the  less  marked  and  less  chronic  cases,  a  total  of  five  or  six  applications  or 
even  less  may  be  sufficient,  while  in  the  more  stubborn  instances  treatment 
must  be  continued  even  longer  than  above  indicated.     A  small  portion  of  the 


p-9 


#3 


0'  * 

C/9 


Fig.  77. 

Camera  lucida  drawings  of  Endameha  gingivalis  (Gros),  stained  with  iron  hematoxylin; 
a  and  b  showing  the  usual  central  or  subcentral  position  of  the  nucleus;  c,  a  and  e, 
examples  with  the  nucleus  in  eccentric  position;  /,  g  and  h,  examples  showing  nucleus  in 
compressed  condition;  t,  an  example  with  two  nuclei  (it  is  suspected,  although  not  known, 
that  the  small  ameba  lying  within  the  same  space  in  the  stained  film  had  been  recently 
separated  from  the  larger  one).      (Smith  and  Barrett.) 

purulent  contents  of  one  of  the  pockets  is  taken  up  on  a  suitable  instrument 
such  as  a  flat  stiff  scaler  not  more  than  from  one-tenth  to  one-eighth  of  an 
inch  in  width,  and  this  is  diffused  in  a  drop  of  slightly  warmed  normal  saline 
solution  deposited  on  a  warm  slide.  This  preparation  is  covered  with  an  ordi- 
nary thin  cover-glass,  and  the  fresh  and  unstained  material  examined  at  once, 
without  further  preparation,  using  a  4  mm.  objective.  If  so  desired,  one  may 
use,  in  order  to  bring  out  to  some  degree  the  nucleus  in  the  living  parasite,  a 
small  amount  of  very  dilute  neutral  red  solution  diffused  under  the  cover-glass. 
In  the  midst  of  the  pus  and  red  blood  cells  and  myriads  of  bacteria  and  lepto- 
thrix  threads,  the  protozoa  may  be   readily  made  out  with  the  microscope. 


390 


PHABMACO-THERAPEUTICS 


They  are  actively  motile  in  such  preparations  for  fifteen  minutes  or  more  at 
ordinary  temperature.  Permanent  preparations  are  best  made  by  spreading 
the  contents  of  the  pocket  upon  a  cover-glass  and  fixing,  vrhile  moist,  in  a  sat- 
urated solution  of  mercury  bichlorid  in  alcohol,  and  afterward  washing  out 
the  mercury  with  iodin  and  alcohol  and  staining  by  the  Giemsa  method.  For 
diagnostic  purposes,  however,  examination  of  unprepared  material  for  the  mov- 


Fig.  78. 

Photomicrograph    of   Endameba   gingivalis    (Gros),    stained    with    iron    hematoxylin,    from 
material  from  pyorrhea  pocket.     (Smith  and  Barrett.) 


-^ 

■M 

f^ 

m 

1 

7^ 

w 

l/M 

fWj 

r 

-/^ 

'. 

1 

Fig.  79. 

Composite  outlines  of  moving  Endameba  gingivalis  (Gros),  including  five  camera  lucida 
sketches;  time  included,  twenty  seconds;  to  show  activity  of  movement  and  long  type  of 
pseudopod  at  times  assumed;  magnification  as  in  Fig.  76.     (Smith  and  Barrett.) 


ing  organism  is  quite  sufficient,  and  in  some  ways  advantageous,  particularly 
in  the  matter  of  economy  in  time.  Caution  as  to  the  maintenance  of  the 
warmth  of  the  preparation  should  be  insisted  upon — a  matter  which  is  not  of 
much  difficulty  in  the  warmer  months  but  may  require  the  use  of  a  warm 
stage  in  the  winter  of  such  a  climate  as  that  of  this  city.  When  seen  in  its 
living  state  the  organism  is  a  gelatinous-looking  cell,  ranging  up  to  about  30 


EMETICS  391 

microraillimeters  in  diameter,  moving  in  characteristic  amebiform  manner,  and 
thrusting  out,  here  and  there  about  its  periphery,  one  or  two  thick  lobose  to 
digitate  pseudopodia,  with  a  distinct  but  scant  ectosarc  (best  seen  in  the 
pseudopods  and  about  their  bases),  and  with  a  granular  and  more  or  less 
vacuolated  endosarc.  The  nucleus  is  practically  always  invisible  in  the  un- 
stained specimen;  in  stained  preparations  it  is  small  in  size  and  contains  but 
little  chromatin,  in  grains  or  scant  threads.  The  nuclear  membrane  is  thin  and 
poorly  defined,  and  the  karyosome  small.  In  the  cytoplasm  there  are,  at  least 
in  the  larger  examples,  and  as  a  rule  seen  best  after  staining,  numerous  coarse 
ingested  bodies,  remnants  of  leucocytic  nuclei,  of  red  blood  cells,  and  often  a 
large  number  of  bacteria.  Undigested  red  blood  cells  are  occasionally  seen  in 
the  living  amebic  body;  but  these,  if  watched  only  for  a  few  minutes,  rapidly 
disappear  owing  to  the  effectiveness  of  the  amebic  intracellular  digestive 
agencies. 

It  is  perhaps  well  to  suggest  that,  in  withdrawing  the  contents  of  the  pockets 
for  examination,  violent  scraping  of  the  wall  of  the  pocket  be  avoided,  so  as 
to  prevent  the  admixture  of  any  great  proportion  of  blood,  which,  of  course, 
adds  to  the  confusion  already  sufficiently  great  because  of  the  pus  and  myriads 
of  vegetable  organisms. 

Bass  and  Johns  suggest  the  following  procedures  in  preparing 
stained  experiments: 

Staining. — (1)  The  smear  is  first  fixed  to  the  slide  by  passing  the  slide, 
film  side  up,  through  the  flame  of  an  alcohol  lamp  or  Bunsen  burner  one  or 
more  times  until  the  slide  feels  fairly  hot  when  applied  to  the  back  of  the 
hand. 

(2)  Apply  one  or  two  drops  of  Czaplewski's  carbol-fuchsin  for  a  few 
seconds.    Einse  off  excess  of  stain  with  water. 

(3)  Apply  Lceflfler's  methylene-blue  for  fifteen  to  thirty  seconds.  Usually 
the  stain  is  applied  for  a  short  time,  rinsed  off  with  water  and  examined 
against  a  light  background.  If  not  stained  sufficiently  the  stain  is  again  ap- 
plied.   Properly  stained  preparations  have  a  deep  purple  color. 

(4)  Blot  off  excess  of  water.  Dry  in  the  air.  Examine  with  the  1/12  mm. 
oil  immersion  lens. 

Examination  and  Identification. — Material  from  the  proper  location  in  the 
lesions  will  show  about  as  many  red  blood  cells  as  pus  cells,  with  a  good  many 
large  cells  from  the  granulating  surface,  many  bacteria,  spirochetes  and  a 
large  number  of  endamebse.  The  red  blood  cells  stain  a  deep  red.  Pus  cells 
show  a  bright  purple  irregularly-shaped  nucleus  with  a  light  pink  protoplasm. 
The  larger  tissue  cells  show  a  red  to  pink  staining  protoplasm  with  a  small 
purple  nucleus.  Bacteria  and  spirochetes,  depending  upon  the  species  and 
varieties,  stain  blue,  purple,  or  bright  red.  The  endamcbaj  vary  from  about 
the  size  of  a  pus  cell  to  about  four  times  their  size.  The  ondoplasm  stains 
a  deep  blue  and  is  surrounded  by  the  slightly  irregular  border  of  purple  stain- 
ing ectoplasm.  A  small,  round  or  oval  nucleus  staining  a  deep  port  wine  color 
is  found  centrally  along  with  from  one  to  ten  or  twelve  inclusion  bodies  of 


392  PHARMACO-THERAPEUTICS 

nuclear  material  staining  a  deep  purple  or  blue-black.  These  inclusion  bodies 
are  contained  in  vacuoles  shown  by  a  clear  ring  about  each  one.  Usually  the 
whole  endameba  appears  to  be  surrounded  by  a  clear  zone  showing  the  retrac- 
tion of  the  protoplasm  while  drying.  Once  properly-stained  endamebas  are 
found,  it  will  be  readily  appreciated  that  their  appearance  is  so  characteristic 
that  they  will  never  be  mistaken  for  any  other  body  likely  to  be  found  in 
pus  from  the  locality  in  question. 


CATHARTICS. 

Cathartics,  commonly  known  as  physic,  are  remedies  used  for 
the  purpose  of  unloading  the  bowels  per  anum — defecation.  They 
were  used  much  more  freely  in  olden  times;  in  fact,  to  take 
medicine  internally  was  at  one  time  almost  synonymous  with  tak- 
ing a  physic.  The  term  physic  has  been  used,  and  is,  to  some  ex- 
tent, employed  at  present,  to  indicate  the  art  of  therapeutics. 

With  the  progress  of  medical  knowledge  quite  a  number  of 
specific  terms  have  been  created  to  designate  the  many  sub- 
divisions of  this  large  group.  The  Greeks  spoke  of  cathartics  and 
the  Romans  of  purgatives,  both  meaning  to  clean  up,  when  they 
referred  to  drugs  which  were  employed  to  free  the  body  of  diseased 
juices  and  accumulated  feces.  Again,  the  term  evacuant,  to  re- 
move the  feces,  is  used,  while  aperient  indicates  to  open  the  bowels. 
A  drastic,  to  force  through,  is  a  powerful  cathartic,  while  a  laxa- 
tive is  a  drug  which  means  softening  of  the  fecal  matter.  Car- 
minatives are  employed  to  remove  gases  from  the  bowels.  The 
flow  of  bile  is  increased  by  a  cholagogue,  and  to  produce  watery 
evacuations  hydragogues  are  administered.  The  term  saline  indi- 
cates a  cathartic  consisting  of  neutral  salts  of  the  metals  of  the 
alkalies  or  alkaline  earths. 

The  formation  of  the  feces  is  the  result  of  the  accumulation  of 
nonabsorbable  remnants  of  the  mixed  foodstuffs — cellulose,  ani- 
mal fibrous  tissue,  cartilage,  etc.  With  the  aid  of  the  glandular 
secretions,  ferments,  and  intestinal  bacteria,  putrefaction  is  pro- 
duced, which  results  in  the  formation  of  carbon  dioxid,  marsh  gas, 
sulphuretted  hydrogen,  ptomains,  and  the  many  other  products  of 
decomposition.  The  fecal  matter  remains  in  the  lower  intestines 
for  about  fifteen  hours;  through  the  absorption  of  fluid  the  formed 
feces  are  produced,  which  finally  are  expelled  by  peristalsis,  in- 
volving a  complicated  process  of  nervous  impulses.  The  inhibition 
of  normal  peristalsis  produces  acute    and    chronic    constipation 


CATHARTICS  393 

(obstipation) ;  to  relieve  this  condition,  cathartics  are  indicated. 
In  acute  constipation  cathartics  may  be  taken  with  impunity, 
while  in  chronic  constipation  other  means — as  regulation  of  the 
diet,  etc. — are  to  be  preferred  to  the  continued  administration  of 
cathartics.  In  acute  catarrh  of  the  bowels,  and  sometimes  in  acute 
poisoning,  cathartics  are  of  service.  Obesity  is  occasionally  favor- 
ably influenced  by  the  judicious  administration  of  cathartics. 
Cathartics  are  not  indicated  in  peritonitis,  sutures,  or  other  surgi- 
cal interferences  with  the  bowels,  in  extreme  general  weakness, 
and  in  hemorrhage  of  the  bowels. 

The  action  of  cathartics  depends  very  much  on  the  nature  of  the 
remedy  employed.  Direct  irritation  of  the  smooth  muscular  coat 
of  the  bowel  is  rarely  accomplished;  the  great  bulk  of  cathartics 
act  by  indirect  irritation  of  the  motor  ganglia  of  the  intestines, 
which  results  in  an  increased  peristalsis.  The  quick  removal  of  the 
feces  by  these  cathartics  prevents  their  formation  into  a  solid  mass. 
The  resultant  stool  is  usually  of  a  fluid  nature.  Vegetable  ma- 
terials which  are  rich  in  pectin — manna,  tamarinds,  honey,  jellies, 
preserves,  etc. — form  colloidal  solutions  in  the  intestines,  and  re- 
tain large  quantities  of  water,  and  by  their  softening  influence  act 
as  mild  laxatives.  The  various  alkali  salts — the  sulphates,  phos- 
phates, and  tartrates — which  are  diffusible  only  with  difficulty,  and 
the  salts  of  the  alkaline  earth  metals — magnesium  carbonate, 
sulphate,  etc. — act  in  a  somewhat  similar  manner ;  incidentally  they 
are  mild  irritants.  The  salines  retain  in  the  bowel  the  water  of  their 
own  solution;  by  osmosis  they  abstract  fluid  from  the  surround- 
ing blood  and  lymph  tissues  until  they  become  isotonic  with  the 
body  fluids,  and  by  the  increased  bulk,  fluidity,  and  peristaltic 
movement  produce  copious  stools.  The  readily  diffusible  salts — 
sodium  chlorid,  etc. — do  not  retain  the  water  of  their  solution,  and 
are  easily  absorbed  by  the  bowel.  Certain  mild  cathartics  act  by 
indirect  stimulation  of  the  motor  ganglia,  which  is  caused  by  their 
bulky  mass — coarse  bread,  corn  bread,  pumpernickel,  regulin. 
Dangerous  irritation,  followed  by  severe  inflammation  and  annoy- 
ing tenesmus,  are  often  caused  by  drastics — croton  oil,  jalap, 
colocynth — and  are  rarely  employed  at  present. 

Cathartics  are  conveniently  divided  into  vegetable  cathartics  and 
saline  cathartics;  sulphur,  calomel,  and  liquid  petrolatum  occupy 
an  exempted  position  among  the  cathartics. 


394  PHARMACO-THERAPEUTICS 

Vegetable  Cathartics. 

Rhubarb  ;  Rheum,  U.  S.  P. ;  Rhei  Radix,  B.  P. ;  Rhubarbe,  F.  , 

Rhabarber,  G. 

It  is  the  dried  rhizome  of  Rheum  officinale  and  other  species.    It 
is  principally  administered  as  an  extract,  fluidextract,  or  tincture. 
Average  Dose. — 15  grains  (1  Gm.). 

Aloes  ;  Aloe,  U.  S.  P. ;  Aloe  Barbadensis,  B.  P. ;  Aloe,  F.,  G. 

It  is  the  inspissated  juice  of  the  leaves  of  Aloe  vera  and  other 
species.  It  is  principally  administered  in  its  purified  form  as  an 
extract,  tincture,  or  wine. 

Average  Dose. — 4  grains  (0.25  Gm.), 

Cascara  Sagrada;  Rhamnus  Purshiana,  U.  S.  P.; 
Cascara  Sagrada,  B.  P. 

It  is  the  dried  bark  of  Rhamnus  purshiana.     It  is  principally 
administered  as  a  fluidextract,  tincture,  or  aromatic  syrup. 
Average  Dose. — 15  grains  (1  Gm.). 

Frangula;  Frangula,  U.  S.  P.;  Buckthorn;  Ecorce  de  Bouro- 
dine,  F.  ;  Faulbaumrinde,  G. 

It  is  the  dried  bark  of  Rhamnus  frangula.    It  is  principally  ad- 
ministered as  a  fluidextract  or-  tincture. 
Average  Dose. — 15  grains  (1  Gm.). 

COLOCYNTH  ;  CoLOCYNTHIS,  U.  S.  P.  ;   COLOCYNTHIDIS  PULPA,  B.  P.  ; 
COLOQUINTE,  F.  ;  KoLOQUINTEN,   G. 

It  is  the  peeled  dried  fruit  or  pulp  of  Citrullus  colocynthis.     It 
is  best  administered  as  an  extract  in  pill  form. 
Average  Dose. — 1  grain  (0.06  Gm.). 

Jalap ;  Jalapa,  U.  S.  P.,  B.  P.;  Jalap  Tubereux,  F. ;  Jalap- 
penknollen,  G. 

It  is  the  dried  tuberous  root  of  Exogonium  purga.     It  is  prin- 
cipally employed  as  a  powder,  extract,  or  tincture. 
Average  Dose. — 15  grains  (1  Gm.). 


CATHARTICS  395 

Podophyllum;  Podophyllum,  U.  S.  P.;  Podophyli  Rhizoma, 
B.  P.;  Mandrake  Root;  Vegetable  Calomel;  Podophyllum, 
F,  G. 

It  is  the  dried  rhizome  of  Podopliyllum  peltatum.     It  is  prin- 
cipally administered  as  an  extract  or  resin  in  pill  form. 
Average  Dose. — 714  grains  (0.5  Gm.). 

Senna;  Senna,  U.  S.  P.;  Senna  Alexandrina,  B.  P.;  Feuilles 
de  Sene,  F.  ;  Sennesblatter,  G. 

The  dried  leaflets  of  Cassia  acutifolia.  Senna  is  principally  ad- 
ministered in  powder  form  or  as  an  infusion. 

Average  Dose. — 60  grains  (4  Gm.). 

Tamarind;  Tamarindus,  U.  S.  P.,  B.  P. ;  Figs,  Ficus,  U.  S.  P., 
B.  P. ;  Prunes,  Prunum,  U.  S.  P.,  B.  P.  They  contain  sugar  and 
pectin  in  variable  quantities,  and  are  mild  laxatives. 

Castor  Oil  ;  Oleum  Ricini,  U.  S.  P.,  B.  P. ;  Huile  de  Ricin,  F.  ; 

RiCINUSOL,  G. 

It  is  the  fixed  oil  expressed  from  the  seeds  of  Ricinus  communis. 
Average  Dose. — 4  fluidrams  (16  C.c). 

Croton  Oil;  Oleum  Tiglii,  U.  S.  P.;  Oleum    Crotonis,   B.    P.; 
HuiLE  de  Croton  Tiglium,  F.  ;  Krotonol,  G. 

It  is  a  fixed  oil,  expressed  from  the  seeds  of  Croton  tiglium. 
Average  Dose. — 1  minim  (0.05  Gm.). 

Saline  Cathartics. 

Sodium  Phosphate;  Sodii  Phosphas,  U.  S.  P.,  B.  P.;  NaaHPO, 
+I2H2O;  Phosphade  de  Soude,   F.  ;   Natriumphosphat,    G. 

It  appears  in  large,  colorless  crystals,  odorless,  and  having  a 
saline,  cooling  taste.  It  is  soluble  in  about  5.5  parts  of  water  and 
almost  insoluble  in  alcohol.  Sodium  phosphate  is  best  admin- 
istered in  the  compound  solution  of  sodium  phosphate,  U.  S.  P., 
or  as  the  effervescent  sodium  phosphate,  U.  S.  P. 

Average  Dose. — 30  grains  (2  Gm.). 


396  PHARMACO-THERAPEUTICS 

Sodium  Sulphate;  Sodii  Sulphas,  U.  S.  P.,  B.  P.;  NaoS04 
4-IOH2O;  Glauber's  Salt;  Sal  de    Glauber,    F. ;    Glauber- 

SALZ,  G. 

It  appears  in  large,  colorless  crystals,  odorless,  and  having  a 
saline  taste.  It  is  soluble  in  about  3  parts  of  water  and  almost 
insoluble  in  alcohol. 

Average  Dose. — 240  grains  (16  Gm.). 

Magnesium  Sulphate;  Magnesii  Sulphas,  U.  S.  P.,  B.  P.; 
MgSO^+THjO;  Epsom  Salt;  Sel  d 'Epsom,  F. ;  Bittersalz,  G. 

It  appears  in  small,  colorless  needles,  without  odor,  and  having 
a  cooling,  saline,  and  bitter  taste.  It  is  soluble  in  1  part  of  water 
and  almost  insoluble  in  alcohol.  It  is  best  administered  as  the 
effervescent  magnesium  sulphate,  U.  S.  P.,  B.  P. 

Average  Dose. — 240  grains  (16  Gm.). 

Solution  of  Magnesium  Citrate;  Liquor  Magnesii  Citratis,  U.  S. 
P.  It  is  a  solution  of  magnesium  citrate,  with  an  excess  of  citric 
acid,  to  which  potassium  bicarbonate  is  added.  The  solution  must 
be  kept  tightly  corked,  and  effervesces  when  poured  from  the  bottle. 
Average  dose,  12  fluidounees  (360  C.c). 

Potassium  Bitartrate  ;  Potassii  Bitartras,  U.  S.  P. ;  Potassii 
Tartras  Acidus,  B.  P.;  KHC^H^Og;  Cream  of  Tartar;  Creme 
de  Tartare,  F.  ;  Weinstein,  G. 

It  is  a  white,  gritty  powder,  odorless,  and  has  a  pleasant, 
acidulous  taste.  It  is  soluble  in  about  200  parts  of  water  and  al- 
most insoluble  in  alcohol. 

Average  Dose. — 30  grains  (2  Gm.). 

Potassium  Citrate;  Potassii  Citras,  U.  S.  P.,  B.  P.;  KaCgHgOv 
-f-HjO ;  Citrate  de  Potasse,  F.  ;  Kaliumcitrat,  G. 

It  is  a  white,  granular  powder,  odorless,  and  having  a  cooling, 
saline  taste.  It  is  soluble  in  about  0.5  part  of  water  and  almost 
insoluble  in  alcohol.  It  is  best  administered  as  effervescent  potas- 
sium citrate,  U.  S.  P. 

Average  Dose. — 15  grains  (1  Gm.). 

Potassium  and  Sodium  Tartrate;  Potassii  et  Sodii  Tartras,  U. 
S.  P. ;  Soda  Tartarata,  B.  P. ;  KNaC4H,Oe+4H20 ;  RocJielle  Salt; 


CATHARTICS  397 

Sel  de  Seignette,  F, ;  Seignettesalz,  G.  It  is  a  white  powder,  odor- 
less, and  having  a  cooling,  saline  taste.  It  is  soluble  in  about  1.2 
parts  of  water  and  almost  insoluble  in  alcohol.  Average  dose,  120 
grains  (8  Gm.). 

Compound  Effervescing  Powder;  Pulvis  Effervescens  Com- 
positus,  U.  S.  P.;  Pulvis  Sodce  Tartaratce  Effervescens,  B.  P.; 
Seidlitz  Powder;  Poudre  de  Sedlitz,  F. ;  Sedlitz  Pulver,  G.  This 
powder  is  put  up  in  two  papers,  blue  and  white;  the  blue  one 
<!ontains  a  mixture  of  31  parts  of  sodium  bicarbonate  and  93  parts 
i)f  potassium  and  sodium  tartrate,  and  the  white  paper  contains 
tartaric  acid — 160  grains  (10.4  Gm.)  of  Rochelle  salt  to  38  grains 
(2.25  Gm.)  of  tartaric  acid.  When  the  powders  are  dissolved 
separately  in  water  and  the  solutions  are  mixed,  the  tartaric  acid 
acts  on  the  sodium  bicarbonate  and  releases  carbonic  acid,  with 
effervescence. 

Sulphur,  Washed;  Sulphur  Lotum,  U.  S.  P.;  Sulphur  Sub- 
LiMATUM,  B.  P. ;  Washed  Flowers  of  Sulphur  ;  Soufre  Lavi^, 
F. ;  Gereinigte  Schwefelblumen,  G. 

It  is  prepared  by  washing  sublimed  sulphur  with  water  and 
ammonia.  It  is  a  fine,  yellow  powder,  insoluble  in  water  and 
slightly  soluble  in  alcohol. 

Average  Dose. — 60  grains   (4  Gm.). 

Mercurous  Chlorid,  Mild;  Hydrargyri  Chloridum  Mite,  U.  S. 
P. ;  Hydrargyri  Subchloridum,  B.  P. ;  HgCl ;  Calomelas  ; 
Calomel,  E.,  F.,  G. 

It  is  a  white,  heavy,  impalpable  powder,  odorless  and  tasteless; 
insoluble  in  alcohol,  water,  and  ether.  It  is  incompatible  with 
bromids,  iodids,  sulphates,  sulphids,  carbonates,  limewater,  alka- 
lies, ammonia,  cocain,  etc.  It  is  best  administered  in  powder 
form. 

Average  Dose.— 2  grains  (2.125  Gm.).  As  an  alterative  it  is 
given  in  "broken"  doses,  %  grain  (0.01  Gm.)  every  two  hours, 
followed  by  a  saline  cathartic. 

Mass  of  Mercury;  Massa  Hydrargyri,  U.  S.  P. ;  Blue  Mass;  Blue 
Pill.  It  is  prepared  by  rubbing  together  metallic  mercury  with 
honey  of  rose,  glycerin,  althaea,  and  licorice  until  the  globules  of 
mercury  are  invisible  under  a  lens  magnifying   ten   diameters. 


398  PHARMACO-THERAPEUTICS 

Blue  mass  contains  about  33  per  cent  of  mercury.  It  is  admin- 
istered in  pill  form.    Average  dose,  4  grains  (0.25  Gm.). 

Phenolphthalein,  U.  S.  P. — It  is  a  compound  obtained  by  the 
interaction  of  phenol  and  phthalic  anhydride.  It  is  used  as  a  pur- 
gative in  doses  of  II/2 — 3  grains  (0.1 — 0.2  6m.).  It  is  best  adminis- 
tered in  tablet  form,  and  should  be  thoroughly  chewed  and  followed 
by  a  tumblerful  of  water.  It  forms  the  principal  constituent  of 
many  of  the  popular  modern  laxatives ;  purgen,  prunoids,  probilin, 
laxaphen,  phenolax,  etc. 

Recently,  liquid  petrolatum,  petrolahitn  liquidum,  U.  S.  P.,  either 
obtained  as  such  or  sold  under  various  copyrighted  names,  is  used 
extensively  as  a  laxative.  When  administered  internally  it  is  not 
absorbed  from  the  intestinal  canal,  but  acts  purely  mechanical  as  a 
lubricant  of  the  tract.  It  may  be  given  in  doses  of  one  or  two 
tablespoonfuls  at  bedtime,  the  amount  to  be  increased  or  reduced 
according  to  conditions,  age,  etc. 

Solutions  of  potassium,  sodium,  magnesium  sulphate,  and  other 
alkaline  salts  in  the  form  of  bitter  waters  are  much  employed  as 
mild  laxatives.  The  more  important  natural  mineral  waters  are 
Hunyadi-Janos,  Carlsbad,  Friedrichshall,  Seidlitz,  etc.  These 
waters  are  principally  drank  in  the  early  morning  on  an  empty 
stomach. 

Saline  Cathartic  Solution. 

IJ     Magnesii  sulphatis  5  j   (30  Gm.) 

Acid,  sulphur,  dil.  gtt.  xv   (1  C.c.) 

Syr.  limonis  flS  j   (30  C.c.) 

Aquae  ad  flg  iv  (120  C.c.) 


M 

Si 
hours 


JUL. 

Sig. :     Tablespoonful  in  a  glassful  of  water  every  three 
>urs. 


Tonic  Laxative, 


R     Tinct.  nuc.  vomic.  gtt.  xv  (1  C.c.) 

Fluidextract.  rhamni  pursh. 

aromatic,  flB  j   (30  C.c.) 

Syr,  limonis  ad  flg  ij   (60  C.c.) 

M. 

Sig.:     Half  a  teaspoonful  every  two  hours. 


CIRCULATORY    STIMULANTS    AND    DEPRESSANTS  399 

CIRCULATORY  STIMULANTS  AND  DEPRESSANTS. 

Drugs  which  are  employed  for  the  purpose  of  stimulating  the 
circulation  are  known  as  circulatory  stimulants,  and  they  are 
sometimes  referred  to  as  vasoconstrictors,  while  drugs  which  de- 
press the  circulation  are  spoken  of  as  circulating  depressants  or 
vasodilators.  Those  drugs  which  exercise  a  tonic  influence  on  the 
heart  are  known  as  analeptics. 

Every  organ  of  the  body  requires  for  its  undisturbed  function 
an  uninterrupted  rich  supply  of  continuously  renewed  blood.  The 
blood  is  inclosed  in  a  system  of  elastic  tubes — the  arteries  and 
veins — and  the  heart.  The  latter  exercises  the  double  function  of 
a  muscular  suction  and  pressure  pump,  and  by  rhythmic  con- 
traction and  relaxation  produces  circulation.  The  blood  flows 
through  the  heart  in  the  direction  of  the  valves,  which  open  only 
toward  the  arteries.  The  heart  is  divided  into  two  halves,  and 
each  half  into  two  chambers — the  auricle  and  the  ventricle ;  the 
various  dividing  walls  are  provided  with  a  number  of  valves.  The 
four  chambers  of  the  heart  are  essential  for  the  proper  sucking 
and  pumping  of  the  blood  from  the  veins  into  the  arteries.  The 
rhythmic  contraction  and  relaxation  constitutes  the  heart  cycle; 
the  contraction  of  the  auricular  musculature  constitutes  the 
auricular  systole — it  forces  the  blood  into  the  ventricles.  The 
latter  are  now  filled  completely  with  blood  (its  back  flow  being 
prevented  by  the  closure  of  the  tricuspid  and  mitral  valves),  and, 
as  soon  as  the  inner  pressure  of  the  ventricles  is  above  that  of  the 
pulmonary  artery  and  the  aorta,  the  semilunar  valves  open  and  the 
blood  is  ejected  into  the  arteries  by  the  ventricular  systole.  A 
period  of  rest  and  relaxation  of  ventricles  and  auricles  now  fol- 
lows, which  constitutes  the  auricular  and  ventricular  diastole. 
The  heart  beats  about  seventy-two  times  a  minute,  and  each  cycle 
of  the  heart  occupies  about  0.8  seconds. 

When  the  normal  functions  of  the  circulation  are  disturbed  and 
the  heart  has  to  perform  an  increased  amount  of  labor,  nature  has 
fortunately  provided  for  this  emergency  by  increasing  the  diam- 
eter of  the  fibers  of  the  heart  muscle,  and  thereby  hypertrophy  of 
the  heart  is  established.  The  heart  muscle  may  carry  on  this  in- 
creased work  for  years,  provided  the  patient  avoids  any  undue 
exertion,  without  materially  interfering  with  his  welfare;  it  com- 
pensates the  weak  heart.     To  relieve  or  mitigate  this  compensa- 


400  PHARMACO-THERAPEUTICS 

tion,  digitalis  is  the  supreme  remedy.  It  performs  two  functions 
— it  slows  the  heart  beat  and  increases  the  arterial  pressure. 
Strophanthus,  especially  its  g-alkaloid,  has  a  somewhat  similar 
action  as  digitalis. 

Occasionally  it  is  necessary  to  quickly  overcome  an  acute  weak- 
ness of  the  heart — "heart  failure."  A  direct  stimulation  is  best 
accomplished  with  caffein,  camphor,  and  alcohol,  or  ether;  to  in- 
sure their  prompt  action,  they  should  be  injected  hypodermically, 
except  caffein. 

For  the  purpose  of  increasing  the  activity  of  the  vasomotor 
centers,  which  results  in  an  increase  of  the  blood  pressure,  stim- 
ulants are  administered.  They  act  by  direct  or  by  reflex  action. 
The  most  powerful  direct  stimulation  is  produced  by  the  absence 
of  oxygen  from  the  inspired  air;  this  procedure  is  not  employed 
therapeutically.  The  principal  drugs  employed  for  such  purpose 
are  strychnin  and  to  some  extent,  atropin.  Strychnin  acts  prin- 
cipally on  the  vasomotor  centers  of  the  medulla  oblongata;  it 
increases  the  blood  pressure  and  the  heart  beat  becomes  slower. 
To  insure  quick  action  strychnin  is  preferably  administered  by 
hypodermic  injection.  As  an  antidote  in  intoxication  with 
paralyzing  poisons — general  anesthetics,  opium  and  its  salts, 
choral  hydrate — it  acts  as  a  powerful  excitant.  Atropin  in  small 
doses  increases  the  pulse  rate  as  a  result  of  its  inhibitory  influence 
on  the  vagi  nerves;  it  apparently  antagonizes  the  action  of 
morphin,  and  is  much  lauded  as  an  antidote  in  morphin  poison- 
ing. 

Paralysis,  or,  rather,  diminished  activity  of  the  vasomotor  cen- 
ters, is  principally  accomplished  by  the  administration  of  the 
nitrites.  Certain  halogen  substitution  compounds — chloroform, 
chloral  hydrate,  etc. — have  a  pronounced  paralyzing  influence  on 
the  nervous  system.  Their  action  on  the  vasomotor  centers  is  too 
severe,  however,  and  consequently  they  are  not  used  for  such  pur- 
poses. The  nitrites  dilate  the  peripheral  vessels,  especially  those 
of  the  face  and  in  the  brain,  and  they  increase  the  heart  beat. 
Amyl  nitrite  and  nitroglycerin  are  the  principal  representatives 
of  this  group.  The  vessel  wall  may  be  directly  influenced  by  cer- 
tain drugs,  which  are  applied  locally,  or  they  may  act  by  internal 
administration  through  the  blood.  The  dilation  or  contraction  of 
the  vessel  wall  is  the  result  of  the  action  of  the  drug  on  the 
muscle  fibers.     Dilation  of  vessels  is    quickly    obtained    by  ex- 


CIRCULATORY    STIMULANTS    AND    DEPRESSANTS  401 

ternally  applied  irritants  (see  Irritants  and  Counterirritants), 
while  contraction  of  the  vessel  is  the  direct  sequence  of  the  appli- 
cation of  certain  astringents.  (See  Astringents.)  A  few  drugs 
exhibit  specific  action  as  vasoconstrictors  without  possessing  all 
the  functions  of  an  astringent.  The  two  typical  representatives 
of  locally  applied  vasoconstrictors  are  cocain  and  the  extract  of 
the  suprarenal  gland.  Cocain  is  principally  used  as  a  local  anes- 
thetic. Its  vasoconstrictor  side  action  is  a  valuable  factor  in  the 
production  of  local  anesthesia.  (See  Local  Anesthesia.)  The  ex- 
tract of  the  suprarenal  gland,  on  account  of  the  ready  decomposi- 
tion of  its  solution,  is  not  used  therapeutically.  The  hydrochloric 
salt  of  its  alkaloid  or  its  synthetic  substitutes  are  the  principal 
pharmaceutic  preparations  employed  for  such  purposes.  Ergot 
and  golden  seal  (hydrastis),  or  their  alkaloids,  are  principally  ad- 
ministered internally  for  the  purpose  of  powerfully  contracting  the 
muscular  coat  of  the  uterus ;  both  drugs  seem  to  possess  a  specific  af- 
finity for  the  smooth  muscle  fibers  of  this  organ.  Styptol  and  styp- 
ticin,  which  are  both  chemically  related  to  hydrastin,  are  important 
local  vasoconstrictors;  their  functions  have  been  referred  to  under 
Hemostatics  and  Styptics. 

Digitalis;  Digitalis,  U.  S.  P.;  Digitalis  Folia,  B.  P.;  Foxglove; 
Feuilles  de  Digitale  Pourpree,  F.  ;  Fingerhut,  Gr. 

They  are  the  dried  leaves  of  Digitalis  purpurea,  collected  from 
plants  of  the  second  year's  growth.  Digitalis  is  preferably  admin- 
istered in  the  form  of  an  infusion ;  the  extract  and  the  tincture  are 
claimed  to  be  less  effective.  The  alkaloids  of  digitalis  are  uncer- 
tain in  their  action. 

Average  Dose. — 1  grain  (0.06  Gm.). 

Strophantus;   Strophanthus,  U.   S.  P.;   Strophanthi  Semina, 
B.  P.,  Strophantus,  F.,  G. 

It  is  the  ripe  seed  of  StropJiantlius  Kombe,  and  is  preferably  ad- 
ministered as  the  tincture.  The  alkaloid  of  strophanthus  (stro- 
phanthinum,  U.  S.  P.)  varies  much  in  its  composition.  G-strophan- 
thinin  is  claimed  to  be  a  reliable  preparation. 

Average  Dose. — 1  grain  (0.06  Gm.). 


402  PHARMACO-THERAPEUTICS 

Strychnin  Sulphate;  Strychnine  Sulphas,  U.  S.  P.;  (C21H22 
N202)2-H2SOi+5H20;  Sulfate  de  Strychnine,  F.  ;  Schwefel- 
saures  Strychnin,  G. 

It  is  the  sulphate  of  the  alkaloid  strychnin,  prepared  from 
Strychnos  nux-voniica.  It  appears  in  colorless  crystals,  or  as  a 
white  crystalline  powder,  odorless,  and  having  an  intensely  bitter 
taste.  It  is  soluble  in  about  31  parts  of  water  and  65  parts  of  al- 
cohol.    Strychnin  and  its  salts  are  intensely  poisonous. 

Average  Dose, — %o  grain  (0.0015  Gm.). 

Strychnin  Nitrate;  Strychnine  Nitras,  U.  S.  P. ;  Strychnin  Hy- 
drochlorid;  Strychnines  Hydrochloridiim,  B.  P.  They  are  em- 
ployed practically  for  the  same  purpose  and  in  the  same  dose  as 
strychnin  sulphate. 

Amyl  Nitrite;  Amylis  Nitris,  U.  S.  P.;  Amyl  Nitris,  B,  P.; 
AzoTiTE  d'  Amyl,  F.  ;  Amylnitrit,  G. 

It  is  a  liquid,  containing  about  80  per  cent  of  amyl  nitrite.  It 
appears  as  a  yellowish  liquid,  having  a  peculiar,  ethereal,  fruity 
odor  and  a  pungent,  aromatic  taste.  It  should  be  kept  in  hermeti- 
cally sealed  glass  bulbs  in  a  cool  and  dark  place.  Small  glass 
"pearls"  containing  from  2  to  5  drops  of  amyl  nitrite  are  now 
procurable.  When  needed,  a  capsule  is  broken  in  a  napkin  and 
held  before  the  patient's  face.  "Spirets"  are  small  glass  capsules 
containing  5  drops  of  amyl  nitrite;  they  are  wrapped  in  lint,  and 
when  used  they  are  crushed  between  the  fingers. 

Average  Dose. — 3  minims  (0.02  C.c), 

Spirit  of  Nitroglycerin  ;  Spiritus  Glycerylis  Nitritis,  U,  S,  P,  ; 
Liquor  Trinitrini,  B,  P,  ;  Spirit  of  Glyceryl  Trinitrate  ; 
Spirit  of  Nitroglycerin  ;  Spirit  of  Glonoin, 

It  is  an  alcoholic  solution,  containing  1  per  cent  by  weight  of 
glyceryl  trinitrate.  It  is  a  clear,  colorless  liquid,  having  the  odor 
and  taste  of  alcohol;  even  small  doses  produce  violent  headache. 
Glyceryl  trinitrate  is  also  marketed  in  tablet  form;  they  readily 
deteriorate.  The  solution  must  be  handled  with  extreme  care  to 
avoid  explosion. 

Average  Dose, — 1  minim  (0.05  C.c). 


circulatory  stimulants  and  depressants  403 

Desiccated  Suprarenal  Glands;  Glandule.  Suprarenale  Sicc^, 
U.  S.  P. ;  Glands  Surrenales  Desse  chees,  F.  ;  Getrocknete 
Nebenniere,   G. 

Source  and  Character. — They  are  the  suprarenal  glands  of 
the  sheep  or  ox,  freed  from  fat,  and  cleaned,  dried,  and  powdered. 
They  form  a  light  yellow-brown  amorphous  powder,  having  a 
slight,  characteristic  odor,  and  are  partially  soluble  in  water.  The 
powdered  glands  or  their  extract  are  rarely  used  at  present;  their 
isolated  active  principle  has  superseded  the  cruder  preparations. 
The  alkaloid  is  known  as  adrenalin,  epinephrin,  suprarenin,  etc., 
and  is  employed  as  a  1 :1,000  solution.    The  solutions  are  preserved 


mm- 


Fig.  80. 


Tracing  the  blood  pressure  under  synthetic  suprarenin.  One  milligram  of  the  supra- 
renin hydrochlorid  solution,  1:1,000,  was  injected  at  a  into  the  carotid  artery  of  a  dog. 
(Abderhalden-Muller.) 

with  small  quantities  of  chloretone,  thymol,  etc.  Epinephrin  solu- 
tions do  not  keep  well,  exposure  to  air  or  minute  quantities  of  alkali 
quickly  destroy  them ;  this  latter  process  is  hastened  by  diluting  the 
solutions.  Kecently  an  artificial  substitute  has  been  introduced, 
and  is  known  as  synthetic  suprarenin.  Chemically  it  is  the  dioxy- 
phenylethanolmethylamin  hydrochlorid,  or,  briefly,  the  methylam- 
inoalcohol.  In  its  chemic,  physiologic,  and  physical  properties, 
synthetic  suprarenin  is  strictly  identical  with  the  products  obtained 
from  the  adrenal  glands,  except  that  it  is  optically  inactive.  It  is 
a  chemically  pure  body,  which  does  not  vary  in  its  composition, 
and  consequently  it  is  superior  to  the  product  of  the  natural  gland 
(See  Active  Principle  of  the  Suprarenal  Capsule.) 


404  PH  ARM  A  CO-THERAPEUTICS 

Average  Dose  of  Epinephrin  Hydrochlorid. — ^ooo  gi'ain 
(0.00006  Gm.). 

Average  Dose  of  Epinephrin  Hydrochlorid  Solution,  1 :1,000. 
— 1  minim  (0.05  C.c). 

Therapeutics. — When  epinephrin,  even  in  very  minute  doses,  is 
injected  into  the  circulation  of  an  animal,  it  causes  a  quick  and 
powerful  rise  of  blood  pressure,  with  a  strengthening  of  the  heart 
beat.  In  a  few  minutes  the  increased  pressure  passes  off  slowl}'. 
No  other  known  drug  will  produce  a  similar  effect.  Local  applica- 
tion on  mucous  surfaces  or  hypodermic  injection  of  epinephrin 
solution  produces  a  pronounced  anemia  within  the  affected  area. 
Its  continuous  application  causes  a  peculiar  thickening  of  the  ves- 
sel walls,  which  results  in  a  degeneration  of  their  muscular  coat. 
Epinephrin  solutions  are  locally  applied  to  control  small  hemor- 
rhages, or  by  injection  to  produce  anemia  of  the  field  of  operation. 
Combined  with  cocain  or  novocain,  it  restricts  the  action  of  these 
local  anesthetics  to  the  involved  area,  thus  lessening  their  absorp- 
tion and  thereby  increasing  their  action,  and  incidentally  lessen- 
ing their  poisonous  effects.     (See  Local  Anesthesia.) 

The  internal  administration  of  epinephrin,  with  the  hope  of  act- 
ing through  the  blood  after  being  absorbed,  is  useless;  no  effect 
will  follow  its  absorption  into  the  circulation.  Epinephrin  is  of 
benefit  in  hay  fever,  in  epistaxis,  and  in  small  hemorrhages  from 
the  mouth,  nose,  ear,  etc.  The  quantity  necessary  for  hypodermic 
injection  is  extremely  small ;  one  minim  of  1 :1,000  solution,  di- 
luted with  a  cubic  centimeter  of  an  isotonic  salt  solution,  is  amply 
sufficient  for  the  purpose,  and  5  minims  constitute  the  maximum 
dose  of  a  single  injection,  which  should  not  be  exceeded. 

Caffein,  camphor,  validol,  alcohol,  and  ether  have  been  referred 
to  under  Cerebral  Stimulants. 

Camphor  Solution  for  Hypodermic  Injection. 

R     Camphorae  3  ss  (2  Gm.) 

Athens  flS  j   (30  C.c.) 

M. 
Sig. :     A  cubic  centimeter  injected  in  cases  of  collapse. 

RESPIRATORY  STIMULANTS  AND  DEPRESSANTS. 

Respiration  is  divided  into  external  and  internal  respiration. 
External  respiration  is  carried  on  by  the  lungs;  it  consists  in  the 


RESPIRATORY   STIMULANTS   AND   DEPRESSANTS  405 

absorption  of  oxygen  and  the  giving  off  of  carbon  dioxid  by  the 
blood  when  it  passes  through  the  lungs.  Internal  respiration  is 
concerned  with  the  interchanges  of  oxygen  and  carbon  dioxid  by 
the  capillaries  and  the  tissue  cells.  The  apparatus  connected  with 
respiration  consist  of  the  nose,  naso-pharynx,  trachea,  bronchi, 
bronchioli,  and  the  alveoli  of  the  lungs.  By  the  prolonged  ab- 
sence of  oxygen  and  the  increase  of  carbon  dioxid  the  centers  of 
respiration  become  paralyzed.  The  normal  rhythmic  movements 
of  the  latter  are  regulated  by  certain  ganglia  located  within  these 
centers.  Most  of  the  inhaled  oxygen  is  chemically  bound  to  the 
hemoglobin,  and  only  a  small  part  is  physically  dissolved  in  the 
blood.  Carbon  dioxid  is  always  present  in  the  air  in  small  quan- 
tities (0.03  per  cent)  ;  when  this  amount  is  materially  increased, 
the  air  becomes  "foul."  The  exhaled  air  of  man  or  animal  is  not 
poisonous,  provided  it  does  not  contain  too  large  quantities  of  car- 
bon dioxid.  Pure  carbon  dioxid  is  a  poisonous  gas,  and  produces 
asphyxia.  Some  physiologists  claim  that  the  normal  carbon  dioxid 
of  the  air  performs  an  important  function  in  respiration,  and  that 
it  is  the  permanent  stimulant  of  the  respiratory  centers. 

Respiration,  aside  from  the  changes  occurring  in  the  composition 
of  the  air,  may  be  materially  influenced  by  injuries  of  the  muscles 
of  the  thorax  or  diaphragm;  by  contraction  of  the  larger  and 
smaller  bronchi  and  alveoli,  which  may  interfere  with  the  ready 
passage  of  the  air;  by  interference  with  the  ready  flow  of  blood 
through  the  capillaries,  and  thereby  preventing  close  contact  with 
the  oxygen;  by  an  inability  of  the  blood  to  absorb  oxygen — when 
the  blood  is  already  chemically  saturated  with  some  other  gas,  as  in 
potassium  chlorate  poisoning,  etc. ;  or  by  an  inability  of  the  tissue 
cells  to  take  up  oxygen,  as  in  poisoning  with  cyanids.  The  usual 
result  of  these  many  disturbances  is  dyspnea — that  is,  a  difficult  or 
labored  breathing. 

Dyspnea  tends  to  remove  the  obstructions  in  various  ways. 
Forcible  respiration  is  the  usual  method  employed  by  nature  to 
give  relief.  The  artificial  provision  of  oxygen,  including  air,  under 
slight  pressure  is  usually  of  marked  benefit,  and  incidentally 
quickly  replaces  the  accumulated  carbon  dioxid.  Drugs  which  are 
intended  to  relieve  the  various  causes  of  disturbances  of  respira- 
tion depend  on  the  nature  of  the  latter.  Antiseptics,  astringents, 
and  styptics  are  principally  called  for  in  tubercular  diseases  of  the 
lungs.     Oil  of  turpentine  and  other  essential    oils    of    the    pine 


406  PHARMACO-THERAPEUTICS 

family,  oleo-resins,  cresote,  and  guaiacol  are  largely  employed  in 
phthisis;  they  are  preferably  administered  in  a  very  fine  state  of 
division  by  using  an  atomizer.  Hypersecretion  of  the  mucous 
membranes  is  checked  by  mild  doses  of  atropin  sulphate,  while 
an  increased  secretion  is  usually  readily  obtained  by  the  adminis- 
tration of  expectorants.  Ipecac,  potassium  iodid,  and  ammonium 
chlorid,  together  with  many  drugs  containing  sugar  and  muci- 
laginous substances — licorice,  marshmallow,  Irish  moss,  mullein, 
elder  flowers,  squills,  honey,  etc. — are  much  lauded  in  liquefying 
the  dried-up  secretions.  The  irritation  of  a  cough  is  best  delayed 
by  opium  or,  morphin.  Irritability  of  the  centers  of  respiration  is 
usually  readily  reduced  by  morphin  and  quebracho.  True  asthma 
— tonic  spasms  of  the  smooth  muscle  fibers  of  the  bronchial  alveoli 
— is  relieved  by  carefully  adjusted  doses  of  atropin  sulphate,  and 
by  lobelia,  amyl  nitrite,  and  the  fumes  of  saltpeter.  The  centers 
of  respiration  may  be  directly  stimulated  by  hypodermic  injec- 
tions of  strychnin  sulphate.  Artificial  respiration  is  of  prime  im- 
portance in  cases  of  complete  cessation  of  respiration ;  it  is  referred 
to  under  General  Anesthetics, 

Cough  Mixture. 

IJ     Ammonii  chlorid.  3  j    (4.0  Gm.) 

Tinct.  opii  camphor.  fl3  iv   (15  C.c.) 

Fluidextract.  Hquoric.  flS  j   (30  C.c.) 

Aquae  ad  flS  iv  (120  C.c.) 

M, 

Sig, :    Tablespoonful  three  times  a  day. 


TONICS. 

Tonics,  sometimes  referred  to  as  rohorants,  are  medicines  in- 
tended to  give  strength  or  "tone"  to  the  system.  Tonics,  like 
alteratives,  do  not  belong  to  a  definite  pharmacologic  group ;  they 
do  not  act  on  specific  organs,  but  on  the  organism  as  a  whole. 
Tonics  are  administered  for  the  purpose  of  increasing  the  nutrition 
of  the  whole  body  by  a  slight  stimulation  of  all  its  vital  functions, 
and  thereby  give  gi'eater  resistance  to  the  organism  against  external 
deleterious  influences.  Iron,  arsenic,  phosphorus,  and  calcium  are 
the  principal  types  of  true  tonics.  Iron  is  known  as  exercising  a 
specific  influence  on  the  blood,  and  consequently  it  is  sometimes 
referred  to  as  a  hematinic.    Arsenic  seems  to  cause  a  definite  un- 


TONICS  407 

known  stimulation  of  cell  activity  in  general,  and  phosphorus  fur- 
nishes most  necessary  components  of  the  soft  tissues  as  well  as  of 
the  bones.  Calcium  is  the  essential  component  of  bone  structure, 
and  is  present  in  the  blood. 

Iron. 

Iron  is  a  normal  constituent  of  the  blood^pt  is  present  in  the 
hemoglobin  of  the  red  corpuscles.  Hemoglobin  is  the  agent  which 
is  directly  concerned  with  the  interchanges  of  oxygen  and  carbon 
dioxid  in  indirect  respiration.  The  average  daily  waste  of  iron 
derived  from  the  red  blood  corpuscles  and  other  cells  amounts  to 
about  Yq  to  14  grain  (0.01  to  0.016  Gm.).  This  loss  of  iron  is 
more  than  readily  replaced  by  the  organic  iron  which  is  contained 
in  the  ordinary  mixed  foodstuffs.  In  certain  diseases,  however, 
which  are  principally  the  result  of  an  altered  composition  of  the 
blood  (chlorosis),  or  of  an  insufficiency  of  its  quality  and  quantity 
(anemia),  the  natural  supply  of  iron  is  not  sufficient,  and  an  ar- 
tificial increase  of  the  iron  component  is  essential.  Usually  within 
a  comparatively  short  time  marked  improvement  in  the  blood  is 
shown  after  the  iron  administration.  Just  how  iron  acts  in  the 
body  is  not  fully  known  at  present,  but  it  is  probably  certain  that 
it  causes  a  direct  stimulation  of  the  blood-forming  centers — the 
erythroblasts  in  the  marrow  of  the  long  bones. 

The  iron  of  the  blood  and  of  the  foodstuffs  is  a  peculiar  organic 
compound,  which  is  not  altered  by  the  ordinary  iron  prccipitants. 
The  inorganic  iron  preparations  are  represented  by  ferrous  and 
ferric  salts.  "WTien  they  are  taken  internally  in  moderate  doses, 
only  very  small  quantities  of  these  salts  are  absorbed ;  for  the  most 
part  they  are  excreted  with  the  feces.  Concentrated  iron  salt  solu- 
tions act  as  caustics  on  the  mucous  membrane  of  the  gastro-in- 
testinal  canal.  Chemists  have  endeavored  to  produce  organic  iron 
compounds  analogous  to  those  existing  in  the  body.  Quite  a  large 
number  of  organic  compounds,  which  represent  the  iron  in  a  so- 
called  "masked"  (nonionic)  form,  have  been  introduced  within 
the  last  decade.  The  prototype  of  these  compounds  is  ferratin, 
a  ferric  albumin  acid  containing  6  per  cent  of  iron.  Ferratin 
is  readily  absorbed,  and  is  easily  borne  by  the  patient;  neverthe- 
less clinicians  of  wide  experience  claim  that  with  this  or  any  other 
masked  iron  no  better  therapeutic  results  are  obtained  than  with 


408  PHARMACO-THERAPEUTICS 

the  old-fashioned  inorganic  compounds  or  the  ferruginous  mineral 
waters. 

Manganese  is  sometimes  added  to  iron  to  increase  its  action  on 
the  blood;  its  therapeutic  value  is  denied  by  most  clinicians.  It 
is  usually  administered  as  an  organic  iron  and  manganese  pepto- 
nate  in  a  weak  alcoholic  solution  flavored  with  aromatics. 

Iron  is  usually  administered  after  meals,  and  the  many  official 
preparations  leave  a  wide  choice  for  the  selection  of  the  proper 
form  of  medicament.  Quite  a  large  number  of  iron  preparations 
are  described  in  the  pharmacopeias,  and  it  is  quite  unnecessary 
to  enumerate  all  of  these  compounds.  The  preparations  especially 
in  favor  with  the  clinicians  are : 

Mass  of  ferrous  carbonate,  massa  ferri  carhonatis,  U.  S.  P. ;  Val- 
let's  mass;  average  dose,  4  grains  (0.25  Gm.).  Pills  of  ferric  car- 
bonate, piliilce  ferri  carhonatis,  U.  S.  P.,  B.  P. ;  average  dose,  2 
pills.  Saccharated  ferrous  carbonate,  ferri  carhonas  saccTiaratus, 
U.  S.  P.,  B.  P.;  average  dose,  4    grains    (0.25    Gm.).      Various 


Fig.  81. 
Glass  tube  for  taking  corrosive  medicines. 

wines,  syrups,  and  solutions  containing  iron  salts,  and  the  many 
organic  preparations,  among  which  the  following  are  the  more 
prominent:  Ferratin,  carniferin,  hematogen,  hemol,  hemogallol, 
ovoferrin,  triferrin,  and  the  solution  of  ferro-mangan  peptonate. 
The  latter  solution  has  been  apparently  very  largely  prescribed  in 
the  last  few  years.  Certain  inorganic  iron  compounds,  especially 
solutions  of  iron  chlorid,  iodid,  lactate,  sulphate,  and  pyrosulphate, 
readily  destroy  the  enamel  and  cause  a  pronounced  black  discolora- 
tion of  the  teeth.  This  is  also  true,  as  Morgenstern  has  shown,  in 
x-egard  to  many  of  the  ferruginous  mineral  waters.  Most  of  these 
iron  compounds  act  on  the  enamel,  principally  by  virtue  of  their 
acid  component;  reduced  iron,  saccharated  iron,  and  masked  iron 
do  not  affect  the  teeth.  When  corrosive  iron  preparations  are  pre- 
scribed, they  should  be  taken  well  diluted  and  through  a  glass 
tube  which  reaches  sufficiently  far  back  in  the  mouth.  Immediately 
after  taking  an  iron  compound,  the  mouth  should  be  thoroughly 
rinsed. 


TONICS  409 

Iron  Tonic. 

H     strychnin,  sulphat.  gr.  ss   (0.03  Gm.) 

Liquor,  ferro-mangan. 

pepton.  fl5  iv  (120  C.c.) 

M. 

Sig. :     Dessertspoonful  three  times  daily  after  meal?. 
Caution:     Avoid  acid  fluids. 


Arsenic. 

The  action  of  arsenic  on  the  animal  organism  manifests  itself 
as  a  typical  protoplasm  poisoning;  it  kills  the  cell  by  chemically 
disturbing  its  contents.  Administered  in  therapeutic  doses,  arsenic 
exercises  a  definite  function  on  the  tissues  of  the  skin,  on  the  blood- 
forming  organs,  on  the  osseous  tissues,  and  apparently  on  the 
lymphatic  system.  Furthermore,  arsenic  seems  to  favorably  in- 
fluence certain  pathologic  disturbances,  and  it  is  frequently  em- 
ployed in  syphilis,  in  remittent  fevers,  especially  in  pernicious 
malaria,  in  neuralgias,  and  in  other  nervous  diseases.  The  thera- 
peutic action  of  arsenic  is  not  fully  understood.  It  is  believed  that 
arsenic  produces  some  form  of  irritation  which  stimulates  the  cells 
to  greater  activity.  This  supposition  is  based  on  observations  made 
in  regard  to  its  action  on  the  tissues  when  administered  as  a  poison. 
For  a  detailed  description  of  the  action  of  arsenic  trioxid  on  the 
pulp  see  page  230. 

Arsenic  is  principally  administered  in  the  form  of  Fowler's 
solution,  in  pill  form,  and  as  natural  arsenical  mineral  water.  The 
principal  spas  which  are  known  to  be  rich  in  arsenic  are  those  of 
Kudowa  (Silesia)  and  of  Levico  and  Eoncegno  (Tyrol).  Recently 
organic  preparations  of  arsenic  in  the  form  of  an  alkyl  com- 
pound, and  known  as  atoxyl  arsenate,  have  been  introduced.  They 
are  intended  for  internal  or  hypodermic  administration.  Arsenic 
preparations  are  preferably  taken  after  meals. 

Solution  of  Potassium  Arsenite;    Liquor   Potassii    Arsenitis, 
U.  S.  P.;  Liquor  Arsenicalis,  B.  P.;  Fowler's  Solution. 

It  is  a  1  per  cent  solution  of  arsenic  trioxid  neutralized  with 
potassium  bicarbonate  in  water,  to  which  compound  tincture  of 
lavender  is  added  to  give  it  color  and  flavor. 

Average  Dose. — 3  minims  (0.2  Co.). 


410  PHARMACO-THERAPEUTICS 


Arsenical  Tonic. 


IJ     Liquor,  potass,  arsenit.  fl3  iij    (12  C.c.) 

Aquae  menth.  pip.  ad  flS  j   (30  C.c.) 

M. 

Sig. :  5  drops  in  water  three  times  daily  after  meals.  The 
dose  is  increased  daily  by  1  drop  until  15  drops  three  times 
daily  are  taken. 


Phosphorus. 

Phosphorus  is  present  in  extremely  small  quantities  in  the  al- 
bumin of  every  cell,  and  as  calcium  phosphate  it  furnishes  an 
important  inorganic  component  of  the  bones  and  teeth.  The  thera- 
peutic administration  of  phosphorus  is  restricted  principally  to 
diseases  of  the  bones — rachitis  and  osteomalacia.  If  the  true  tonic 
action  of  phosphorus  is  desired,  it  should  be  given  in  an  oily  solu- 
tion; cod  liver  oil  is  much  employed  for  this  purpose.  The  many 
solutions  of  hypophosphites,  lactophosphates,  and,  recently,  of 
glycerophosphates  in  syrup,  which  constitute  an  important  item 
in  popular  medicine  and  with  many  practitioners,  are  ill  adapted 
for  this  purpose;  they  are  not  absorbed  by  the  tissues,  and  prac- 
tically all  of  the  administered  phosphates  leave  the  body  with  the 
urine.  Through  their  rich  sugar  component  they  frequently  de- 
range the  digestion. 

Phosphorus  poisoning  has  been  frequently  observed  in  those  ex- 
posed to  its  vapors,  especially  in  match  factories.  The  phosphorus 
vapors  pass  through  a  carious  tooth  or  some  other  channel  into  the 
body  of  the  jaw,  causing  a  severe  periostitis,  which  is  followed  by 
necrosis.  Microbal  infection  as  a  sequence  of  the  lessened  resist- 
ance of  the  involved  tissues  is  necessary  to  complete  the  clinical 
picture  of  true  phosphorus  necrosis.  The  substitution  of  amor- 
phous phosphorus  for  the  metalloid  and  improved  dental  hygienic 
conditions  of  the  workmen  have  largely  eradicated  the  causative 
factors  of  this  disease. 

Phosphorus  Tonic. 

B     Phosphorus  gr.  iij   (0.2  Gm.) 

Olei  morrhuae  fl5  xvj   (500  C.c.) 

M. 
Sig. :     Teaspoonf ul  three  times  daily  an  hour  after  meals. 


TONICS  411 

Fluorin. 

Fluorin  in  the  form  of  calcium  fluorid  has  been  recently  sug- 
gested as  a  therapeutic  means  to  increase  the  resistance  of  tooth 
structure  against  caries.  Fluorin  is  principally  found  in  the  en- 
amel, although  only  in  very  small  quantities.  According  to  recent 
analyses  made  by  Hempel  and  Jodlbauer  the  average  amount  of 
fluorin  present  in  the  enamel  of  human  teeth  varies  from  0.26  to 
0.35  per  cent.  Some  observers  claim  that  the  resistance  of  the 
teeth  against  dental  caries  depends  largely  on  the  fluorin  com,po- 
nent  of  the  enamel.  Daninger^  claims  that  the  internal  administra- 
tion of  calcium  fluorin  does  no  harm,  and  that  it  increases  the  firm- 
ness of  the  teeth  and  the  alveoli.  The  children  of  women  who  had 
taken  calcium  fluorid  daily  during  their  pregnancy  had,  without 
exception,  good  teeth.  In  older  children  calcium  fluorid  also  had 
a  good  effect  on  the  formation  of  the  teeth.  Following  Daninger's 
suggestion,  Brissemoret-  has  administered  calcium  fluorid  with  ap- 
parent good  results  in  the  medicinal  treatment  of  dental  caries  and 
in  fractures.  As  yet  no  positive  proof  has  been  furnished  for  this 
supposition ;  but,  as  calcium  fluorid  in  therapeutic  doses  is  a  harm- 
less remedy,  it  seems  reasonable  to  try  it  in  suitable  eases. 

Calcium. 

Calcium  salts  are  important  constituents  of  the  animal  tissues, 
and  form  the  most  important  inorganic  component  of  bones  and 
teeth.  They  are  also  found  in  the  soft  tissues,  and  apparently  ex- 
ercise important  functions  on  certain  ferments — fibrinogen  of  the 
blood,  etc.  The  lime  salts  are  rather  insoluble,  and  when  they  are 
administered  internally  they  usually  leave  the  body  unaltered.  In 
calcium  starvation  in  children — a  deficiency  of  calcium  in  the  food 
— undoubtedly  an  insufficient  amount  of  calcium  is  deposited  in  the 
bones  and  the  teeth.  The  results  are  the  well-known  ill-formed 
bones  in  rickets  and  weak  teeth ;  the  latter  show  a  pronounced  ten- 
dency to  caries.  Rose^  has  recently  shown  that  a  deficiency  of  cal- 
cium salts  must  be,  to  a  large  extent,  held  responsible  for  the  so- 
called  soft  teeth  which  are  so  frequently  met  in  persons  living  in 
regions- in  which  the  natural  calcium  supply  of  the  drinking  water 
is  below  the  normal. 


*Daninger:  Deutsclie  Zahnarztliche  Wochenschrift,  1907,  p.  196. 
*  Brissemoret:  Revue  Internationale  de  M^decine.  1908,  p.  3S1. 
»R6se:  Krdsalzarmut  iind   Kntartung.   1906. 


412  PHARMACO-THERAPEUTICK 

The  normal  individual  ingests  with  his  daily  mixed  diet  in  one 
year  approximately  a  pound  of  calcium  oxid  and  about  seven 
pounds  of  phosphoric  acid.  The  verj^  largest  part  of  these  sub- 
stances is  utilized  by  the  body  for  the  maintenance  of  the  body 
frame.  An  average  human  skeleton  weighs  about  24  pounds,  and 
is  composed,  according  to  Heintz,  of  9.26  pounds  of  lime  and  12.9 
pounds  of  phosphoric  acid.  According  to  the  above  calculation, 
the  mixed  diet  furnishes  in  two  years  more  than  the  necessary 
quantity  of  phosphoric  acid,  while  about  ten  years  wdll  be  required 
to  bring  up  the  amount  of  calcium  salts  to  the  standard.  It  seems 
but  rational,  therefore,  to  select  such  foodstuffs,  especially  for  in- 
fants and  children,  as  contain  a  large  percentage  of  organic  cal- 
cium salts. 

As  to  furnishing  the  body  with  inorganic  substances  in  the  form 
of  calcium,  magnesium,  fluorin,  and  phosphorus  compounds,  which 
are  needed  in  building  up  the  osseous  tissues,  it  is  questionable  if 
these  insoluble  compounds  are  of  benefit.  As  far  as  calcium  salts 
and  phosphorus  compounds  are  concerned,  it  is  known  that  for 
the  most  part  they  are  again  excreted.  If  there  is  a  real  need  for 
these  substances,  a  rational  therapy  points  to  the  utilization  of 
compounds  which  furnish  these  materials  in  organic  combinations 
and  which  are  products  of  nature.  Coarse  wheat  and  rye  flour  are 
rich  in  phosphoric  acid,  while  calcium  salts  (inorganic  lime)  are 
usually  found  in  hard  drinking  water  and  in  most  vegetables,  espe- 
cially beans,  cauliflower,  rutabaga,  and  cabbage.  The  addition  of 
small  quantities  of  lime  water  to  milk  or  drinking  water  apparently 
has  a  beneficial  influence  on  bone  formation.  En  passant  it  may  be 
mentioned  that  the  stories  which  still  circulate  among  the  laity, 
and  to  some  extent  among  practitioners,  regarding  the  removal  of 
lime  salts  from  the  teeth  of  the  mother  during  pregnancy  to  build 
up  those  of  her  offspring,  are  wholly  unfounded.  A  well-regulated 
diet,  rich  in  lime  and  phosphates,  and  sufficiently  coarse  to  call 
forth  vigorous  use  of  the  jaws,  and  regular  exercise  in  the  open 
air,  is  the  foundation  of  a  strong  skeleton  and  sound  teeth. 

ALTERATIVES. 

Alteratives  (to  change)  are  drugs  which  so  favorably  modify 
nutrition  as  to  overcome  morbid  processes;  they  promote  metabol- 
ism.   Modern  pharmacologists  have  discarded  the  term  alteratives 


ALTERAT1\-ES  413 

because  the  drugs  belonging  to  this  group  do  not  act  on  specific 
organs,  but  on  the  organism  as  a  whole.  The  drugs  which  are 
usually  referred  to  as  alteratives  do  not  produce  distinct  symptoms 
when  taken  in  ordinary  doses;  apparently  no  direct  stimulation  or 
depression  can  be  observed,  but  nevertheless  their  therapeutic  in- 
fluence on  the  system  as  a  whole  is  an  assured  clinical  fact. 

The  simplest  remedy  which  causes  changes  in  the  metabolism 
of  the  tissues  is  water.  Water,  when  systematically  ingested, 
cleanses  the  mucous  linings  of  oral  cavity  and  stomach,  and  there- 
by increases  their  activity.  Its  passage  through  the  body  hastens 
the  breaking  down  and  the  removal  of  protoplasm,  which  appears 
in  increased  quantities  as  nitrogenous  compounds  in  the  urine. 
Mild  saline  solutions — sodium  chlorid,  with  minute  additions  of 
sodium  bicarbonate  and  impregnated  with  carbon  dioxid — are  of 
still  greater  benefit  to  the  organism.  Their  influence  on  the 
mucous  linings  of  the  stomach  manifests  itself  in  an  increased  ap- 
petite, and,  as  in  the  drinking  of  plain  water,  the  quantity  of  urine 
and  its  solid  constituents  are  increased.  Ingesting  potassium  salts 
increases  the  excretion  of  sodium  salts  from  the  body;  the  latter 
must  be  replenished  to  restore  the  normal  equilibrium  of  the  tis- 
sue fluids.  Certain  other  salts,  especially  iodin  and  mercury  com- 
pounds, exercise,  aside  from  their  general  action,  a  specific  influ- 
ence on  the  whole  system. 

The  iodids  form  the  most  important  group  of  those  drugs  which 
generically  are  termed  true  alteratives.  Potassium  iodid  is  the 
most  favored  representative  of  this  group.  Of  the  other  iodin 
preparations,  sodium  iodid  and  syrup  of  hydriotic  acid  are  the 
most  universally  employed  compounds.  Almost  equally  as  impor- 
tant as  the  iodin  compounds  are  the  mercury  preparations.  Again, 
only  the  readily  soluble  salts  of  mercury  are  employed  as  altera- 
tives, especially  the  bichlorid  and  the  biniodid  of  mercury.  When 
mercury  passes  through  the  body  of  the  cell  it  forms  a  union  with 
the  albumin  of  its  protoplasm  and  produces  irritation,  which,  de- 
pending on  the  quantity  of  the  absorbed  mercury,  is  more  or  less 
pronounced.  If  the  absorbed  quantity  is  too  large,  the  cell  dies 
from  the  caustic  action  of  the  poisoning.  (See  page  116.)  Of  the 
vegetable  drugs,  sassafras,  guaiac,  sarsaparilla,  etc.,  have  an  old 
reputation  as  being  highly  valued  alteratives;  the  latter  has  been 
much  lauded  as  being  especially  efficacious,  and  is  still  widely 
used   in   the   treatment   of   syphilis.      This   belief   is   wholly   un- 


414  PHARMACO-THERAPEUTICS 

founded;  the  empiric  use  of  sarsaparilla  in  the  form  of  a  syrup, 
decoct,  etc.,  as  a  vehicle  for  potassium  iodid  or  mercury  bichlorid 
has  no  influence  on  the  disease.  The  alkalies  and,  to  some  extent, 
the  acids,  when  ingested  into  the  system,  are  of  importance  in  so 
far  as  they  furnish  chemicals  which  are  needed  for  the  maintenance 
of  the  proper  composition  of  the  bodj'  juices.  The  alkalies  are 
especially  called  for  to  rehabilitate,  under  certain  conditions,  the 
alkalinity  of  the  blood — in  coma  of  diabetes,  where  relatively  large 
quantities  of  acid  are  stored  in  the  organism.  Only  mild  alkalies, 
especially  the  sodium  bicarbonate,  are  useful  for  internal  admin- 
istration; potassium  bicarbonate,  lithium  carbonate,  and  a  few 
others  are  also  used.  The  acids  were  much  more  freely  employed 
in  former  years,  with  the  belief  that  they  could  influence  nutrition. 
The  fruit  acids  act  only  as  relishes. 

lodids. 

lodin,  in  its  pure  state,  is  not  used  internally,  but  sometimes  it  is 
administered  in  the  form  of  an  alcoholic  solution,  well  diluted 
with  water,  or  as  an  oily  solution.  Its  pharmacologic  action  is  most 
pronounced  when  it  is  ingested  in  the  form-  of  its  soluble  salts, 
especially  as  potassium  or  sodium  iodid.  Potassium  iodid  is  decom- 
posed in  the  body  in  the  presence  of  sodium  chlorid  into  potassium 
chlorid  and  sodium  iodid;  both  salts  are  removed  from  the  tis- 
sues by  the  urine  and  through  all  the  glands.  The  iodin  ion  stimu- 
lates the  cells  to  a  higher  activity,  and  incidentally  promotes  ab- 
sorption. The  latter  fact  is  important  in  the  treatment  of  chronic 
metallic  poisoning — lead  and  bismuth  line  in  the  mouth,  argyria, 
etc.  Pathologic  tissues  are  markedly  influenced  by  iodids ;  they  ap- 
parently cause  a  forcible  breaking  down  of  necrotic  and  necrobiotic 
structure;  hence  their  value  in  the  treatment  of  tertiary  stages  of 
syphilis.  The  resistance  of  the  vessel  walls  is  lessened  by  the  iodin 
salts,  and  this  fact  may  help  to  explain  their  beneficial  action  in 
arterio-sclerosis.  lodids  are  often  given  Avith  expectorants  to 
render  the  bronchial  secretions  more  soluble.  Prolonged  admin- 
istration of  an  iodid  is  prone  to  cause  iodism,  w^hich  manifests  it 
self  in  salivation,  frontal  headache,  and  cough.  lodids  have  a  dis- 
agreeable, bitter  taste;  they  are  best  administered  in  milk.  The 
various  organic  compounds  of  iodin  and  their  solutions  are  referred 
to  under  Halogens,  and  Irritants  and  Counter-irritants. 


ALTERATIVES  415 

Potassium  Iodid;  Potassii  Iodidum,  U.  S.  P.,  B.  P.;  KI;  Iodure 
DE  Potassium,  F.  ;  Jodkali,  G. 

It  forms  transparent,  colorless,  or  opaque  white  crystals,  or  a 
white  granular  powder,  having  a  peculiar,  faint,  iodin-like  odor 
and  a  pungent,  saline,  bitter  taste.  It  is  soluble  in  0.7  parts  of 
water,  about  12  parts  of  alcohol,  and  about  2.5  parts  of  glycerin. 
It  is  incompatible  with  calomel,  chloral  hydrate,  acids,  and  alka- 
loidal  and  metallic  salts. 

Average  Dose.— 71/2  gi-ains  (0.5  Gm.). 

Sodium  Iodid;  Sodii  Iodidum,  U.  S.  P.,  B.  P. ;  Nal ;  Iodure  de 
Soude,  F. ;  Jodnatron,  G.  It  forms  colorless,  cubical  crystals,  or  a 
white,  granular  powder,  having  a  saline,  bitter  taste.  It  is  soluble 
in  about  0.5  part  of  water  and  3  parts  of  alcohol.  Average  dose, 
71/2  grains  (0.5  Gm.). 

Ointment  of  Potassium  Iodid;  Unguentum  Potassii  lodidi,  U. 
S.  P.,  B.  P.  It  is  an  ointment  containing  10  per  cent  of  potas- 
sium iodid. 

Concentrated  Potassium  Iodid  Solution. 

IJ     Potassii  iodid.  5  j   (30.0  Gm.) 

Aquae  destill.  ad  flS  j   (30  C.c.) 

M. 

Sig. :     5  drops  three  times  daily  in  a  glass  of  milk. 

Mercury  Salts. 

Mercury  possesses  a  great  affinity  for  albumin,  with  which  it 
very  quickly  enters  into  a  ehemic  union.  The  readily  soluble  mer- 
cury compounds  naturally  act  the  quickest,  while  mercury,  in  its 
metallic  state  or  in  an  insoluble  form,  passes  unaltered  through  the 
body ;  hence  the  assertion  that  red  dental  rubbers,  which  are  often 
colored  with  natural  cinnabar  or  with  artificial  red  mercuric  sul- 
phid  (vermilion),  cause  mercurial  stomatitis  is  wholly  unfounded, 
and  the  same  is  true  of  the  mercury  component  of  amalgam  fillings. 
Mercurials  are  comparatively  easily  absorbed  by  the  mucous  lin- 
ings of  the  intestinal  tract,  and  they  may  then  cause  chronic  in- 
toxications. Acute  poisoning  with  mercurials  is  never  observed, 
but  it  may  be  artificially  induced.  The  absorbed  mercury  is  ex- 
creted by  the  kidneys,  the  intestines,  the  mucous  surfaces,  and  the 
various  glands.     Intense  salivation  is  often  noticed  as  a  result  of 


416  PHARMACO-THERAPEUTICS 

mercury  absorption;  it  is  apparently  due  to  a  direct  stimulation 
of  the  secretory  centers.  The  saliva  contains  mercury  and  has  a 
pronounced  metallic  taste.^ 

The  irritation  caused  by  the  mercury  produces  excoriation  of  the 
mucous  linings  of  the  mouth,  starting  usually  about  the  posterior 
teeth.  Teeth  with  ragged  edges  and  those  covered  with  calcareous 
deposits  invite  irritation.  The  denudation  in  the  presence  of  path- 
ogenic bacteria  soon  leads  to  ulceration,  which  is  accompanied  by 
an  intensely  foul  odor.  The  destruction  of  the  soft  tissues  may  in- 
volve large  parts  of  the  gums,  the  palate,  etc.,  followed  by  per- 
iostitis, but  rarely  by  necrosis  of  the  bone.  Thorough,  hygienic  care 
of  the  oral  cavity  before  and  during  a  course  of  mercurial  treat- 
ment invariably  precludes  the  formation  of  mercurial  stomatitis. 
The  compound  solution  of  hydrogen  dioxid  (see  page  141)  deserves 
to  be  specially  recommended  as  an  oral  antiseptic  under  these  con- 
ditions. 

Mercury  has  been  in  the  past  the  remedy  par  excellence  in  the 
treatment  of  syphilis;  at  present  it  is  largely  replaced  by  salvar- 
san.  Whether  mercurials  act  as  a  direct  poison  to  the  recently  dis- 
covered causative  factor  of  syphilis,  the  spirochete  pallida,  is  as 
yet  not  fully  known.  A  carefully  inaugurated  mercury  treatment 
will  rarely  do  harm.  It  will  keep  the  exciting  organisms  in  check, 
and  prevents  the  secondary  stage  of  syphilis  if  ingested  early.  The 
constitutional  treatment  of  syphilis  belongs  to  the  domain  of  the 
medical  practitioner.  The  administration  of  mercury  depends  on 
its  various  salts,  on  the  metal  in  a  fine  state  of  division  (mercurial 
ointment  or  colloidal  mercury)  and  on  recently  introduced  organic 
compounds.  These  remedies  may  be  introduced  by  internal  admin- 
istration, by  injection,  or  by  inunction.  The  various  salts  of  mer- 
cury have  been  discussed  under  Salts  of  the  Heavy  Metals. 

Very  recently,  mercury  succinimid  has  been  introduced  by 
Wright  and  White  as  a  specific  in  the  treatment  of  pyorrhea  alveo- 

*  Examination  of  saliva  for  mercury  for  the  prevention  of  mercurial  stomatitis  during 
treatment  with  mercury.  Severino  says  that  the  mouth  secretions  during  administration 
of  mercury  pve,  on  addition  of  tincture  of  iodin,  a  red  color,  due  to  the  formation  of 
mercury  biniodid  only  in  case  the  organism  is  oversaturated  with  the  metal.  In  such  an 
event  it  seems  advisable  to  interrupt  the  use  of  mercury  in  order  to  prevent  symptoms  of 
poisoning  with  the  drug,  and  especially  the  appearance  of  a  stomatitis.  Severino  has  de- 
vised a  simple  method  of  carrying  out  this  test.  He  paints  the  anterior  surfaces  of  the 
upper  and  lower  incisor  teeth  with  tincture  of  iodin  and  then  asks  the  patient  to  wet  the 
teeth  thoroughly  with  saliva.  In  case  the  reaction  is  positive,  a  more  or  less  intense  rose- 
colored  stain  appears  on  the  teeth  within  half  a  minute.     (Sahli.) 


ALTERATIVES  417 

laris.  Mercury  succinimid  is  a  white  crystalline  powder,  soluble 
in  75  parts  of  water  and  it  is  not  affected  by  albumen.  According 
to  the  originators  of  this  treatment/  the  dosage  and  method  of  its 
application  is  as  follows: 

"In  this  disease,  in  the  male  patient,  a  deep  muscular  injection  of  mercuric 
succinimid  gr.  1  (65  mgra.)  should  be  administered  every  seventh  day,  until  the 
discharge  of  pus  has  entirely  disappeared,  and  the  gums  have  regained  their 
normal  condition  and  appearance.  If  the  pockets  have  not  been  entirely  ob- 
literated and  the  loose  teeth  have  not  become  firmly  fixed  by  this  time,  they 
will  quickly  do  so  without  further  treatment,  providing  the  hygiene  of  the 
mouth  and  teeth  is  properly  carried  out.  Of  course,  when  a  tooth  socket  has 
become  destroyed  by  alveolar  absorption,  it  is  impossible  for  the  tooth  to  be- 
come fixed,  and  it  should  be  removed.  In  female  patients  the  dose  should  be 
from  gr.  %  (13  nigm.)  to  gr.  %  (26  mgm.)  less  than  that  administered  to 
males.  Mercurialism  of  any  marked  degree  should  be  met  with  smaller  doses 
at  succeeding  injections,  or,  if  the  symptoms  are  severe,  the  mercury  is  dis- 
continued until  they  have  disappeared.  In  treating  cases  complicated  by  a 
secondary  systemic  infection,  the  dosage  and  interval  between  injections  will 
materially  differ  from  the  above,  according  to  the  nature  of  the  secondary 
infection,  whether  acute  or  chronic,  severe  or  mild,  etc.  As  this  question  more 
properly  belongs  to  the  realm  of  internal  medicine,  I  refer  those  interested  to 
my  former  publications.  I  have  seen  several  cases  of  pyorrhea  recover  com- 
pletely under  the  above  treatment  without  local  surgical  intervention,  but  these 
were  those  in  which  calcareous  deposits  and  tartar  had  not  formed,  nor  was 
the  omission  of  local  treatment  desired  by  me,  but  due  to  the  absence  on  leave 
of  my  dental  colleague." 

Precisely  what  we  said  about  the  curative  effect  of  emetin  as  a 
specific  in  the  treatment  of  pyorrhea  will  also  apply  to  the  thera- 
peutic use  of  mercuric  succinimid,  i.  e.,  this  drug  is  an  etiotropic 
remedy  which  destroys  the  spirochete.  But  it  should  be  under- 
stood that  with  the  elimination  of  this  protozoal  agent  alone  pyor- 
rhea is  by  no  means  cured. 

The  late  Ehrlich  introduced  a  number  of  etiotropic  remedies,  i.e., 
specifics  for  the  treatment  of  those  disturbances  caused  by  spiril- 
loses,  especially  syphilis,  malaria,  relapsing  fever  and  frambesia. 
Among  these  remedies,  salvarsan,  also  known  as  "606,"  occupies 
probably  the  foremost  place.  Salvarsan,  dioxydiaminoarseno- 
benzol  hydrochlorid  and  neosalvarsan,  a  sodium  salt  of  the  mother 
substance  and  combined  with  some  inert  inorganic  salts,  contain 
the  trivalent  arsenic.  Salvarsan  contains  about  311/2  per  cent  of 
arsenic  while  3  parts  of  neosalvarsan  are  approximately  equal  to 


»  Wright  and  White:  Dental  Cosmos,  1915.  pp.  405.  779  and  1003. 


418  PHARMACO-THERAPEUTICS 

that  of  2  parts  of  salvarsan.  These  substances  are  preferably  ad- 
ministered intravenously  in  freshly  made  solutions.  Zilz^  highly 
recommended  the  local  application  of  salvarsan  in  freshly  prepared 
10  per  cent  solution  in  water  or  glycerin  or  suspended  in  olive  oil 
or  liquid  paraffin  as  a  topical  remedy  in  Plant- Vincent  angina,  in 
severe  forms  of  stomatitis  and  scorbutic  ulcerations  of  the  oral 
tissues.  With  a  cotton  swab  the  solution  is  applied  3  times  daily 
upon  the  ulcerated  surface  which  has  been  previously  cleansed 
with  warm  physiologic  salt  solution. 

For  Mercurial  Stomatitis. 

R     Vioformi  3  ss   (2  Gm.) 

Glycerini  flS  j   (30  C.c.) 

M. 

Sig. :    Paint  on  the  ulcerated  surfaces  and  cover  with  strips 
of  lint. 

Within  the  last  few  years  a  remedy  has  been  introduced  in  thera- 
peutics which  is  said  to  possess  a  selective  power  on  pathologic 
fibrous  tissues,  causing  its  absorption  and  facilitating  the  stretch- 
ing of  the  cicatrix.  It  is  known  as  fibrolysin,  and,  as  no  other 
pharmacologic  gi'oup  will  allow  its  admittance,  we  prefer  to  discuss 
it  at  this  point. 

Fibrolysin  is  an  aqueous  solution  of  thiosinamin  and  sodium 
salicylate,  marketed  in  sterilized  sealed  tubes,  each  containing  35 
minims  (2.3  C.c),  which  is  equivalent  to  3  grains  (0.2  Gm.)  of 
thiosinamin.  The  solution  is  preferably  introduced  by  intramus- 
cular injections  as  closely  as  possible  to  the  seat  of  the  cicatrix,  but 
not  into  it.  Special  care  is  necessary  not  to  inject  too  close  to  the 
surface,  as  it  may  cause  sloughing.  The  injection  is  made  under 
strict  aseptic  conditions,  and  should  be  repeated  every  second  or 
third  day.  It  is  difficult  to  state  how  many  injections  are  neces- 
sary, as  that  will  depend  largely  on  the  size  of  the  cicatrix. 
Usually  from  eight  to  ten  injections  are  required,  and,  again,  as 
many  as  twenty-five  injections  have  been  necessary  in  large  scars. 
There  are  scarcely  any  unpleasant  after  effects  to  be  recorded; 
slight  rise  of  temperature  and  a  few  cases  of  nausea  and  vomiting 
have  been  noticed.  The  exact  mechanism  by  which  fibrolysin  acts 
is  unknown ;  it  has  been  stated  that  a  hyperemic  congestion  is  estab- 


'Zilz:  Munchener  Medicinische  Wochenschrift.   1913. 


SIALOGOGUES    AND    ANTISIALOGOGUES  419 

lished,  which  may  explain  the  cause  of  the  softening  of  the  fibrous 
tissues. 

The  injection  of  fibrolysin  in  dental  surgery  is  indicated  in  scars 
caused  by  an  alveolar  abscess  discharging  upon  the  face.  These 
scars  are  usually  very  disfiguring,  and  fibrolysin  deserves  to  be 
tried  in  such  cases,  especially  where  there  is  an  opportunity  to  use 
it  soon  after  their  formation. 


SIALOGOGUES  AND  ANTISIALOGOGUES. 

Drugs  which  increase  the  flow  of  saliva  are  known  as  sialogogues 
or  as  ptyalogogues  (to  cause  the  flow  of  saliva),  and  those  which 
diminish  it  are  known  as  antisialogogues.  Human  saliva  represents 
the  mixed  secretions  from  the  three  pairs  of  salivary  glands  and 
the  minute  mucous  glands  distributed  over  the  oral  cavity.  Saliva 
may  be  defined  as  being  a  weak  solution  of  alkalis,  as  present  in 
the  body  juices,  more  or  less  saturated  with  carbon  dioxid.  It 
contains,  furthermore,  several  organic  substances,  among  which 
mucin  and  the  several  ferments  which  accelerate  the  changes  of 
starches  into  maltose,  i.  e.,  the  hydrolysis  of  polysaccharids  into 
soluble  disaccharids.  The  ferments  of  human  saliva  are  repre- 
sented by  the  carbohydrate  splitting  type,  principally  amylase 
(ptyalin)  and,  less  so,  maltase,  although  the  catalyzers,  oxydase 
and  catalase,  are  always  present  in  more  or  less  variable  quan- 
tities. The  physiologic  function  of  mucin  consists  in  mechan- 
ically assisting  the  food  bolus  in  its  easy  passage  into  the  stomach 
and  to  protect  the  oral  mucous  membrane  and  the  teeth  against 
irritating  substances.  Mucin  has  been  held  responsible  by  some 
investigators  (Lohmann,  etc.)  as  a  factor  in  the  production  of 
dental  caries.  This  statement  has  been  emphatically  denied  by 
Miller,  Michel,  and  others.  Mucin  is  insoluble  in  water;  in  the 
presence  of  alkalis  it  forms  a  colloidal  solution,  while  acids  pre- 
cipitate it.  The  so-called  ropy  saliva  contains  larger  quantities 
of  mucin  than  normal  and  by  precipitating  this  sticky  compound 
it  adheres  to  the  surfaces  of  the  teeth  and  thereby  produces  the 
much  discussed  gelatinous  plaques  which  serve  as  a  mechanical 
retainer  of  food  debris  and  bacteria.  (See  Preparations  for  the 
Mouth  and  Teeth.) 


420  PHARMACO-THERAPEUTICS 


Sialogogues. 


Sialogogues  are  indicated  in  an  abnormal  dryness  of  the  mouth. 
Diminished  secretion  of  saliva  results  from  the  injections  of  cer- 
tain drugs — belladonna  (atropin),  henbane,  opium  scopola,  stra- 
monium, etc. — or  from  so-called  ptomain  poisoning,  which  may  re- 
sult from  eating  decaying  meat,  cheese,  fish,  etc.  Many  febrile 
diseases  also  diminish  the  flow  of  saliva,  or  cause  a  drying  up  of 
the  normal  moisture  of  the  oral  mucous  linings.  Dry  mouth 
(xerostomia)  results  from  an  impaired  secretion  of  saliva,  which 
may  be  caused  by  severe  physical  or  psychic  disturbances  of  the 
nervous  system,  diseases  of  the  digestive  tract,  and  other  un- 
known factors.  Atrophy  of  the  salivary  glands  may  destroy 
their  functions  completely.  To  prevent  dryness  of  the  air  in  the 
sick  room,  which  is  very  likely  to  occur  in  the  modern  furnace- 
heated  houses,  pans  filled  with  fresh  water  should  be  placed  about 
the  room.  Small  quantities  of  fresh  drinking  water,  or  acidulated 
with  organic  acids  (lemon  juice,  tartaric  acid),  should  be  given  at 
frequent  intervals  to  the  patient.  Spices  and  the  simple  bitters- 
gentian,  quassia,  columbo,  dandelion,  etc. — as  well  as  the  chewing 
of  semi-solid,  insoluble  material — gum,  rubber,  etc. — increase  the 
flow  of  saliva.  Tobacco,  the  iodin  compounds,  certain  mercury 
preparations,  and  vomiting  also  cause  a  profuse  flow  of  saliva. 

The  supreme  sialogogue  is  pilocarpus  (jaborandi).  It  is  best 
prescribed  as  the  hydrochloric  salt  of  the  alkaloid,  pilocarpin. 
Pilocarpin  acts  on  the  terminations  of  the  secretory  nerves,  espe- 
cially the  minute  fibrils  which  ramify  between  the  epithelial  cells. 
It  is  principally  indicated  in  the  treatment  of  dry  mouth  (xeros- 
tomia). If  this  disease  results  from  nervous  disturbances,  elec- 
tricity is  of  some  value.  While  recovery  from  true  xerostomia  is 
very  problematic,  the  patient  may  be  made  comfortable  by  the  use 
of  pilocarpin. 

Pilocarpin  Hydrochlorid  ;  Pilocarpin/E  Hydrochloridum, 
U.  S.  P.;  C.iH.eN^O^HCl. 

It  is  the  hydrochlorid  of  an  alkaloid  obtained  from  jaborandi 
leaves.  It  appears  in  small  white  crystals,  odorless,  with  a  slightly 
bitter  taste.    It  is  very  soluble  in  water  and  alcohol. 

Average  Dose. — ^  grain  (0.01  Gm.). 


DIAPHORETICS  421 

PiLOCARPiN  Nitrate;  Pilocarpine  Nitras,  U.  S.  P.,  B,  P.; 
C,,H,eN,0,HN03. 

It  is  the  nitrate  of  an  alkaloid  obtained  from  jaborandi  leaves. 
It  forms  a  white  crystalline  powder,  which  is  soluble  in  about  10 
parts  of  cold  water  and  freely  soluble  in  hot  alcohol. 

Average  Dose. — ^2  grain  (0.005  Gm.). 

For  Dry  Mouth. 

B     Pilocarpin.  hydrochlorid.  gr.  v  (0.3  Gm.) 

Aquae  destillat.  fl^  ss  (15  C.c.) 

M. 

Sig. :     5  drops  three  times  daily.    Slowly  increase  the  dose 
by  1  drop  until  from  8  to  10  drops  per  dose  are  taken. 

Antisialogfogues. 

Ptyalism  often  results  from  a  general  poisoning  with  mercury, 
bismuth,  iodin,  and  bromin  preparations,  pilocarpin,  aconitin, 
physostigmin,  etc.  These  poisons  may  have  been  administered  by 
the  mouth,  hypodermically,  or  they  may  have  been  absorbed  from 
wound  surfaces.  The  supreme  remedy  to  stop  the  flow  of  saliva  is 
atropin;  it  paralyzes  the  chlorda  tympani  and  the  sympathetic 
nerve  endings  in  the  salivary  glands.  Small  doses  of  atropin  are 
often  given  advantageously  to  a  patient  afflicted  with  an  abnormal 
flow  of  saliva  prior  to  dental  operations  in  which  the  rubber  dam 
can  not  be  applied. 

Atropin  Sulphate;  Atropine  Sulphas,  U.  S.  P.,  B,  P.; 
(Ci,H23N03)2.H,SO,. 

A  white  crystalline  powder,  prepared  from  the  alkaloid  atropin 
derived  from  belladonna  leaves.  It  has  a  very  bitter  taste,  and  is 
freely  soluble  in  water  and  alcohol. 

Average  Dose. — ^50  grain  (0.0004  Gm.). 

R     Pil.  atropin.  sulphatis  gr.  1/150  (0.0004  Gm.) 

No.  ij 

Sig.:     One  pill  in  the  evening  and  one  in  the  morning  be- 
fore the  dental  operation. 

DIAPHORETICS. 

Diaphoretics  (to  carry  through),  sometimes  called  sudorifics  (to 
sweat),  are  remedies  employed  for  the  purpose  of  increasing 
perspiration.     Normal  perspiration  is  constantly  produced  by  the 


422  PHARMACO-THERAPEUTICS 

sweat  glands,  while  the  so-called  insensible  perspiration  results 
from  the  evaporation  of  water  which  is  derived  from  superficial 
capillaries  and  lymph  channels.  Perspiration  is  spontaneously 
increased  in  heated  surroundings  and  during  muscular  exertion. 
The  control  of  perspiration  is  principally  due  to  specific  nerves, 
although  direct  irritation  of  the  sweat  glands  may  also  produce 
perspiration.  The  true  diaphoretics  excite  the  sweat  centers  as 
well  as  the  peripheral  endings  of  the  sweat  nerves,  while  the  in- 
direct diaphoretics  create  only  an  active  hyperemia  of  the  skin. 
Psychic  influence — fear,  excitement,  etc. — may  also  produce 
perspiration  by  reflex  action.  The  sweat  is  principally  composed 
of  water  (971/2  to  991/2  per  cent),  the  solid  constituents  being 
cholesterin,  aromatic  fatty  acids,  aromatic  oxy-acids,  ethyl  sul- 
phuric acid,  urea,  and  various  salts,  especially  sodium  chlorid  and 
alkaline  sulphates  and  phosphates.  The  normal  fresh  perspira- 
tion of  man  reacts  acid,  but  the  stagnated  sweat  is  usually  alkaline. 
Pure  meat  diet  produces  an  acid  sweat,  while  vegetable  diet  al- 
ways furnishes  alkaline  perspiration.  In  infectious  diseases  the 
sweat  may  eliminate  waste  products  of  microbal  origin,  in  diabetes 
it  may  contain  sugar,  and  in  uric  acid  diathesis  it  may  contain 
uric  acid  salts.  Internally  administered  drugs — salicylic  and 
benzoic  acid  and  their  salts,  iodin,  bromin,  mercury,  lead,  quinin, 
essential  oils,  etc. — may  also  be  excreted  by  the  sweat.  Apparent- 
ly the  production  of  sweat  diminishes  with  the  age  of  the  in- 
dividual. 

Sweating  as  a  therapeutic  procedure  is  rarely  practiced  at  pres- 
ent, except  in  certain  chronic  diseases  and  in  those  conditions 
which  are  generically  termed  "colds."  The  simplest  means  of 
bringing  about  profuse  perspiration  is  by  the  ingestion  of  hot 
fluids  and  a  diminishing  of  heat  radiation  by  wrapping  the  patient 
in  heavy  covers.  Mild  alcoholic  liquids  in  the  form  of  hot  toddies, 
hot  coffee  or  tea  are  especially  productive  of  free  perspiration. 
Pilocarpin  is  the  most  effective  of  all  diaphoretics;  it  may  be  ad- 
ministered as  its  hydrochloric  salt,  or  in  the  form  of  an  infusion 
of  the  jaborandi  leaves.  Elder  flowers  and  linden  flowers  are  still 
largely  used  by  the  laity  for  this  purpose.  Dover's  powder  in 
small  doses,  alone  or  combined  with  the  salicylates  (aspirin),  or 
the  spirit  mindererus  (solution  of  ammonium  acetate,  U.  S.  P., 
B.  P.),  are  frequently  employed  by  the  clinician  for  the  produc- 
tion of  mild  perspiration.     Turkish,  electric  light,  hot  air,  and 


DIURETICS  423 

sun  baths  as  means  of  producing  profuse  perspiration  have  gained 
much  favor  in  recent  years. 

Pilocarpin   and   its  salts   have  been   referred  to   under   Sialo- 
gogues  and  Antisialogogues. 

DIURETICS. 

Diuretics  (to  increase  the  secretion  of  urine)  are  remedies  em- 
ployed for  the  purpose  of  promoting  the  secretion  of  urine.  The 
organ  which  secretes  the  urine  is  the  kidney.  Under  normal  con- 
ditions the  kidney  performs  three  functions — it  maintains  the 
osmotic  equilibrium  of  the  blood,  it  removes  the  end  products  of 
metabolism  of  the  protoplasm,  and  it  eliminates  foreign  substances 
from  the  system.  Urine  is  secreted  by  the  combined  activity  of  the 
glomeruli  and  the  convoluted  tubes;  the  former  secrete  a  fluid — 
poor  in  salts,  but  rich  in  water,  while  the  latter  reverse  the  process 
— rich  in  salts,  poor  in  water.  The  urine  may  be  acid,  alkaline, 
or  neutral  in  reaction.  Occasionally  it  is  desirable  to  produce 
an  increased  flow  of  urine  which  should  react  either  acid,  alkaline, 
or  neutral.  From  a  physiologic  point  of  view  it  is  also  of  interest 
to  know  that  with  the  urine  certain  drugs  are  excreted  which  were 
administered  for  specific  purposes. 

Diuretics  are  administered  for  the  purpose  of  removing  path- 
ologic collections  of  exudates  which  may  have  been  confined  in 
body  cavities  or  between  the  tissues,  as  in  diseases  of  the  heart, 
nephritis,  cirrhosis,  etc.  They  are  also  given  to  remove  poisons 
which  have  entered  the  body  or  which  are  formed  in  the  body, 
and  to  mechanically  flush  the  uriniferous  tubules,  which  may  be 
clogged  by  foreign  materials.  Flushing  of  the  entire  urinary  tract 
includes  the  kidney,  ureter,  and  bladder,  and  it  is  often  employed 
for  the  purpose  of  preventing  the  formation  of  concrements  in 
these  tissues. 

The  many  drugs  which  possess  a  more  or  less  pronounced 
diuretic  action  are  closely  related  to  diaphoretics  and  uric  acid 
solvents.  Water  is  an  important  diuretic,  and  we  have  referred 
to  it  more  particularly  under  Alteratives  and  Uric  Acid  Solvents. 
An  indirect  irritation  of  the  epithelial  coat  of  the  kidneys,  which 
produces  increased  activity,  is  caused  by  many  essential  oils — oil 
of  turpentine,  juniper,  parsley — and  many  roots  and  herbs  which 


424  PHARMACO-THERAPEUTICS 

contain  irritating  substances.  Many  salines,  especially  potassium 
and  sodium  acetate,  sodium  nitrite,  lithium  carbonate,  etc.,  are 
lauded  as  diuretics;  the  solutions  of  ammonium  acetate,  U.  S.  P., 
B.  P.,  and  the  spirit  of  nitrous  ether,  U.  S.  P.,  B.  P.,  enjoy  a 
wide  reputation.  Of  the  heavy  metals,  calomel  in  large  doses 
is  productive  of  an  increased  quantity  of  urine.  A  direct  stimu- 
lation of  the  epithelium  of  the  kidneys  is  readily  obtained  by 
caffein  and  theobromin;  they  do  not  irritate  the  kidneys,  and 
may  be  given  in  comparatively  large  doses.  Theobromin  is  prin- 
cipally administered  in  combination  with  sodium  salicylate,  known 
as  diuretin.  Caffein  has  been  referred  to  under  Cerebral  Stimu- 
lants. 

Theobromin  Sodium  Salicylate;  THEOBROMiNiE  Sodio-Sali- 
CYLAS,  U.  S.  P.;  NaC^H.N^Oa-fNaC^HsOg ;  Diuretin. 

It  is  a  white  powder,  odorless,  and  having  a  saline  taste.  It  is 
freely  soluble  in  water,  but  is  decomposed  in  the  presence  of  car- 
bon dioxid.     It  should  be  given  in  well-diluted  solutions. 

Average  Dose. — 15  grains  (1  Gm.). 

URIC  ACID  SOLVENTS. 

Uric  acid  solvents,  also  referred  to  as  litlwntriptics  or  antilitliics 
(stone  destroyers),  and  as  antiartliritics  (gout  remedies),  are 
drugs  employed  for  the  purpose  of  dissolving  uric  acid  and  in- 
creasing its  excretion. 

Uric  acid  as  a  causative  factor  of  dental  disease  has  been  for 
more  than  a  decade  a  prolific  theme  of  discussion.  Like  all  subjects 
pertaining  to  medicine,  as  well  as  many  other  matters  which  are 
clothed  in  mystery,  it  gives  rise  to  much  unsound  speculation. 
Regarding  the  process  of  uric  acid  formation,  excretion,  destruc- 
tion, retention,  deposition,  and  solution  in  health  and  disease,  very 
few  absolute  facts  are  known,  and  consequently  the  therapeutic 
measures,  as  far  as  remedies  are  concerned,  are  very  limited. 
There  is  probably  no  other  field  in  therapeutics  about  which  so 
little  "truth"  is  known  and  about  which  so  much  "poetry"  is 
written  as  the  uric  acid  problem.^  Apparently,  however,  this  is 
not  true  in  the  mind  of  the  nostrum  maker.     To  him  the  bugbear 


'  Barker:  Truth  and   Poetry  Concerning  Uric  Acid,  Chicago,  1905. 


URIC   ACID   SOLVENTS  425 

of  uric  acid  diathesis  has  been  and  still  is  the  very  shibboleth  of 
uncounted  possibilities.  It  is  not  within  our  present  consideration 
to  enter  into  a  detailed  discussion  of  the  formation  of  uric  acid  in 
the  body.  Let  it  suffice  to  say  that  uric  acid  is  formed  in  the  body 
in  various  ways — as  a  product  of  oxidation  from  the  nucleins  of 
the  tissue  cells  and  from  the  xanthin  bases  of  ingested  foodstuffs, 
or  it  may  be  formed  synthetically  in  the  human  body,  just  as  it 
is  in  the  body  of  birds.  The  acid  is  excreted  in  the  form  of  purin 
bodies — uric  acid  united  with  xanthin  bases.  Uric  acid  diathesis 
is,  in  all  probability,  due  to  increased  presence  or  to  decreased  ex- 
cretion of  formed  uric  acid.  The  first  possibility  may  result  from 
an  increased  formation,  a  decreased  destruction,  or  the  solution 
and  removal  of  gouty  deposits  (tophi).  The  formation  of  tophi 
may  result  from  a  disturbed  function  of  the  excretory  organs, 
which  produces  an  increased  deposition  of  sodium  monourate  in 
the  tissues,  especially  in  the  hyaline  and  fibrous  cartilages,  in  the 
tendons  and  in  the  subcutaneous  and  intramuscular  connective 
tissue,  or  from  a  retention  of  uric  acid  in  the  blood  and  the  other 
tissues.  "It  must  be  admitted  that,  in  the  present  status  of  our 
knowledge,  no  adequate  theory  to  explain  gout  has  been  advanced 
and  that  we  hardly  know  more  than  that  it  is  associated  in  some 
way  with  a  perversion  of  uric  acid  metabolism."  (Krehl.) 

The  rational  treatment  of  uric  acid  diathesis  consists  in  a  well- 
regulated  diet,  together  with  proper  general  hygienic  measures. 
The  diet  should  be  simple  and  rather  spare ;  overloading  the  sys- 
tem must  be  carefully  avoided.  According  to  the  observations  of 
Minkowski,^  the  average  daily  food  should  consist  of  about  4 
ounces  (120  grams)  of  proteins,  2  to  3  ounces  (60  to  90  grams)  of 
fat,  and  8  to  10  ounces  (240  to  300  grams)  of  carbohydrates.  Ac- 
cording to  Haig^  an  average  day's  food  may  consist  of  16  to  20 
ounces  (480  to  600  grams)  of  breadstuffs,  8  ounces  (240  grams) 
of  dried  fruit,  and  8  ounces  (240  grams)  of  fresh  fruit;  each  meal 
consisting  of  5  to  7  ounces  (150  to  210  grams)  of  breadstuffs,  with 
2  to  3  ounces  (60  to  90  grams)  of  dried  fruit,  and  a  similar  quan- 
tity of  fresh  fruit.  A  little  potato  may  often  be  substituted  with 
advantage  for  fruit  at  breakfast ;  some  do  well  with  a  little  potato 
at  each  meal  and  less  fresh  fruit.     Nuts  may  be  added  or  taken 


^Minkowski:     In   Bunge's   Physiologic    Chemistry,    1902. 

2Haig.     Uric   Acid   as   a   Factor   in   the   Causation   of   Disease,    Ivondon,    1904. 


426 


PHARMACO-THERAPEUTICS 


in  place  of  some  of  the  breadstuffs  by  those  who  like  and  can  digest 
them.    Animal  food  should  be  used  very  moderately. 

From  the  following  dietary  a  suitable  uric  acid  free  diet  may  be 
readily  selected: 


Dietary. 


ALLOWED. 

Water,  especially  mild  alkaline  min- 
eral water. 
Very  weak  tea. 

White  meat  of  chicken,  turkey,  quail. 
Meat  soups  in  small  quantities  only. 
All  cereals,  rice,  and  breakfast  foods. 
All  green  vegetables. 
Cabbage  in  moderation. 
Dried  fruits  and  nuts. 
All  breads. 
Eggs   in   moderation. 
Milk. 


PEOHIBITED. 

All    raw    meats    (beef,   mutton,    and 

pork). 
All  glandular  tissues   (kidneys,  liver, 

and  sweetbreads). 
Asparagus,  celery,  radishes. 
Beans  and  peas. 
Coffee. 

All  liquors,  wines,  and  spirits. 
Pastry  and  confections. 
Sharp  sauces  and  mayonnaise. 
Mushrooms. 


Frequent  bathing,  gentle  massage,  and  a  few  hours'  daily  ex- 
ercise will  be  of  marked  benefit.  If  a  month's  vacation  can  be 
taken,  with  much  outdoor  exercise  and  living  the  simple  life,  with 
a  well-controlled  appetite,  it  will  prove  highly  beneficial. 

In  the  treatment  of  dental  diseases  resulting  from  uric  acid 
diathesis,  local  and  general  factors  are  to  be  considered.  An  in- 
creased presence  of  uric  acid  can  be  positively  determined  only 
by  an  analysis  of  the  urine,  and  it  should  always  be  made  in  every 
case  where  the  general  conditions  point  to  its  presence.  Entire- 
ly too  much  guess  work  is  done  in  this  matter  by  the  average 
dental  practitioner.  The  local  treatment  consists  in  the  thorough 
removal  of  the  deposits  about  the  teeth^  and  the  restoration  of 
hygienic  conditions  of  the  oral  cavity.  Internal  medication  is  di- 
rected toward  the  lessening  of  the  formation  of  uric  acid,  and  to 
an  increased  excretion.  The  formation  of  exagenous  uric  acid 
is  readily  controlled  by  a  suitable  diet.  All  foods  rich  in  nucleins 
and  purin  derivatives  are  to  be  avoided — sweetbreads,  liver,  kid- 
neys, etc. ;  in  fact,  all  meats  or  meat  soups  should  be  partaken  of 
sparingly.  Vegetable  proteins,  which  are  found  in  abundance 
in  peas  and  beans,  and  which  are  direct  forestages  of  uric  acid 


^Endelman:  The  Uric  Acid  Problem  as  Related  to  Pericemental  Inflammation,   Dental. 
Cosmos,  1908,  p.   1076. 


URIC    ACID   SOLVENTS  427 

formation,  should  also  be  restricted  in  their  use  as  foodstuffs. 
Whether  the  formation  of  uric  acid  in  the  body  can  be  inhibited 
at  all  is  as  yet  not  proved.  Alcoholic  liquors,  especially  beer,  ex- 
ercise a  known  harmful  influence  on  gouty  predisposition.  It  is 
claimed  that  quinic  (china)  acid  possesses  inhibitory  action  on 
the  formation  of  uric  acid,  and  as  a  consequence  quite  a  number 
of  compounds  containing  this  acid  are  found  on  the  market — 
urosin,  sidonal,  lycetol,  lysidin,  etc.  Their  therapeutic  value  is 
problematic.  An  increase  of  the  destruction  of  uric  acid  in  the 
body  has  also  been  attempted  at  various  times.  So  far  no  positive 
knowledge  exists  to  justify  such  procedures,  although  many  drugs 
are  recommended  for  this  purpose.  Again,  an  increased  excretion 
of  uric  acid  is  favored  by  many  as  a  valuable  therapeutic  aid,  and 
here  at  least  positive  results  can  be  obtained  by  materially  increas- 
ing the  amount  of  urine  excretion.  The  simplest  means  for  such 
purpose  is  the  copious  drinking  of  water.  Ordinary  table  water 
or  mild  alkaline  mineral  waters  will  answer  equally  as  well.  The 
amount  of  water  taken  within  twenty-four  hours  should  be  in- 
creased to  about  one  gallon,  which  equals  approximately  sixteen 
tumblerfuls.  The  salicylates,  especially  lithium  salicylate,  have 
been  highly  recommended — without  proof,  however — as  a  solvent 
or  as  a  means  of  increasing  uric  acid  excretions.  It  is  claimed 
that  many  of  the  alkaline  metallic  salts,  especially  the  salts  of 
lithium,  possess  a  definite  solvent  power  on  uric  acid.  "While  such 
claims  have  never  been  substantiated,  and  are  emphatically  denied 
by  many  investigators,  lithia  is  nevertheless  widely  used  at  present. 
The  administration  of  lithium  compounds  is  of  value  as  sug- 
gestive therapeutics.  A  patient  may  forget,  or  even  object,  to 
carry  out  the  instruction  in  regard  to  the  drinking  of  large  quan- 
tities of  water  which,  in  his  estimation,  may  be  of  little  conse- 
quence, while,  on  the  other  hand,  a  prescription  calling  for  lithium 
citrate  tablets,  with  the  proper  directions,  may  readily  overcome 
this  difficulty.  Kendering  uric  acid,  when  present  in  the  blood, 
more  soluble  may  probably  be  accomplished  by  ingesting  certain 
organic  substances  which  readily  combine  with  the  acid  to  form 
nonsalt-like  compounds.  Of  the  various  preparations  which  are 
suggested  for  such  purposes,  formaldehyd  deserves  mentioning. 
Forroaldehyd  in  the  form  of  hexamethylen,  or  compounds  of  a 
similar  nature,  furnishes  free  formaldehyd  in  the  body.  It  ap- 
pears in  the  urine  as  an  easily  soluble  compound  of  uric  acid,  the 


428  PHARMACO-THEBAPEUTICS 

diformaldehyd-uric  acid.  The  combination  of  these  preparations 
with  colchicum  is  often  of  some  advantage;  the  clinical  results 
obtained  justify  their  empiric  administration.  Atophan  in  doses 
of  from  4-8  grains  (0.25-0.5  Gm.)  increases  uric  acid  excretion 
within  one  hour.  In  doses  of  from  30-45  grains  (2-3  Gm.)  the  nor- 
mal uric  acid  excretion  is  doubled  and  sometimes  even  trebled  in 
twenty-four  hours.  It  is  especially  useful  in  the  acute  attacks  of 
gout.  If  taken  for  4  or  5  days  in  succession,  it  occasionally  de- 
ranges the  digestion. 

The  dental  disturbances  of  uric  acid  diathesis  manifest  them- 
selves principally  in  pericemental  inflammation,  resulting  in  a 
specific  type  of  systemic  pyorrhea  alveolaris.  The  latter  term  is 
unfortunately  still  frequently,  but  wrongly,  interpreted  as  signi- 
fying a  pathologic  entity.  Pyorrhea  alveolaris  is  a  collective  term 
employed  to  designate  a  local  manifestation  of  disease  brought 
about  by  many  causes.  According  to  Miller,  it  may  be  defined 
as  a  chronic  destructive  inflammation  of  the  pericementum,  with 
more  or  less  necrosis  of  the  alveolar  process  of  the  affected  tooth. 
The  constitutional  causes  of  pyorrhea  may  be  manifold;  diabetes, 
syphilis.  Bright 's  disease,  gout,  etc.,  are  among  the  more  promi- 
nent factors  of  its  production.  Gouty  pericementitis,  a  name  given 
by  Pierce^  to  a  form  of  pyorrhea  produced  by  uric  acid  arthritis, 
has  received  much  attention  in  dental  literature.  The  formation 
of  uratic  deposits  occurs  on  the  roots  of  the  teeth — in  the  perice- 
mentum— ^principally  about  the  upper  half  of  the  root.  The  de- 
posited urates  establish  a  point  of  minor  resistance  in  the  peri- 
dental membrane,  and  thus  predispose  it  to  the  invasion  of  pyo- 
genic bacteria.  The  nature  of  the  invading  micro-organisms  de- 
termines the  character  of  the  inflammatory  process.  To  eliminate 
the  endameba  buccalis,  emetin  should  be  applied.  (See  Emetin.) 
In  regard  to  the  systemic  treatment  of  the  gouty  form  of  pyor- 
rhea, it  is  essential  to  conform  to  the  general  rules  of  the  treat- 
ment of  uric  acid  diathesis. 

To  relieve  acute  pain,  the  salicylates,  especially  aspirin,  to- 
gether with  hot  fomentations,  are  beneficial.  If  pericemental 
abscesses  are  present,  an  early  incision,  proper  drainage,  and 
antiseptic  care  is  of  importance  in  the  quick  relief  of  the  local 


'Pierce:  Pyorrhea  Alveolaris,  in  Kirk's  "American  Text  Book  of  Operative  Dentistry," 
1905. 


URIC   ACID   SOLVENTS  429 

symptoms.^  The  thorough  removal  of  the  deposits  from  the  teeth 
and  their  proper  splinting  is  essential  to  the  local  treatment  of 
this  ailment.  To  facilitate  the  ready  disintegration  of  calcareous 
deposits  on  the  roots  of  teeth,  Head^  has  introduced  a  solution  of 
ammonium  bifluorid  which  is  commercially  known  as  tartar  sol- 
vent. Head  has  given  the  following  directions  for  using  this  solu- 
tion: For  the  treatment  of  pyorrhea  scrape  the  roots  with  scalers 
as  thoroughly  as  possible,  and  wash  out  the  pockets  with  warm 
water.  Protect  the  cheek  and  lips  with  a  napkin ;  then,  after  dry- 
ing the  pockets,  fill  them  with  the  solvent  injected  by  means  of  a 
platinum  pointed  syringe,  wiping  off  all  excess  from  the  gums. 
Change  the  napkins  to  avoid  the  possibility  of  any  of  the  solvent 
creeping  up  on  the  cheek  through  capillary  attraction.  At  the 
end  of  two  minutes  rinse  the  mouth  with  water.  Apply  the  sol- 
vents twice  a  week — not  oftener.  During  the  second  or  third  treat- 
ment explore  the  pocket  for  softened  tartar  scales  which  may  not 


Fig.  82. 
Dunn  bifluorid  syringe. 

have  been  entirely  dissolved.  When  the  pockets  begin  to  heal  by 
granulation,  take  care  not  to  allow  instrumentation  to  break  down 
the  adhesions.  When  teeth  are  loose,  without  tartar,  the  repeated 
application  of  the  solvent  twice  a  week  causes  them  to  become 
useful  for  mastication.  Fistulas  may  be  injected  full  of  the  sol- 
vent, and  the  mouth  rinsed  at  once.  The  tartar  solvent  should  al- 
ways be  injected  and  never  inserted  on  cotton.  If  allowed  to  dry 
on  the  mucous  membrane,  it  will  burn  like  phenol.  Ordinary  care 
in  wiping  off  any  excess  will  render  this  impossible. 

It  should  be  remembered  that  this  tartar  solvent,  on  account  of 
its  hydrofluoric  acid  component,  destroys  glass,  and  consequently 
a  glass  syringe  is  ill  suited  for  its  application.  A  special  small 
syringe,  the  Dunn  bifluorid  syringe,  has  been  put  on  the  market 
to  overcome  these  defects.    It  is  made  entirely  of  rubber,  or  it  may 


"Endelman:   Uratic   Deposits   Upon   the   Roots  of  Teeth,  Dental  Cosmos,   1905. 
*Head:   Items  of  Interest,  1909,  p.   174. 


430  PHABMACO-THERAPEUTICS 

be  had  with  a  transparent  celluloid  barrel ;  the  advantages  of  the 
latter  are  obvious.  The  needle  of  the  syringe  is  made  of  iridio- 
platinum. 

Lithium  Carbonate;  Lithii  Carbonas,  U.  S.  P.;  LigCOa. 

A  light  white  powder,  odorless,  and  having  an  alkaline  taste.  It 
is  soluble  in  75  parts  of  water  and  readily  soluble  in  carbonated 
water. 

Average  Dose. — 7i/^  grains   (0.5  Gm.). 

LitMum  Citrate;  Litliii  Citrus,  U.  S.  P.,  B.  P.;  Li3C6H5074- 
4H2O.  A  white,  odorless  powder,  having  a  cooling,  alkaline  taste. 
It  is  soluble  in  about  3  parts  of  water.  Average  dose,  71/2  grains 
(0.5  Gm.). 

LitMum  Salicylate;  Litliii  Salicylas,  U.  S.  P. ;  LiCyHgOg.  A 
white,  odorless  powder,  having  a  sweetish  taste.  It  is  very  soluble 
in  water.     Average  dose,  15  grains  (1  Gm.). 

LitJiium  Citrate,  Effervescent;  Litliii  Citras  Effervescens,  U.  S. 
P.,  B.  P.  A  granular  effervescent  salt,  containing  5  per  cent  of 
lithium  citrate.     Average  dose,  120  grains  (8  Gm.). 

Hexamethylenamin ;    Hexamethylenamina,    U.    S.    p.; 
C6H12N4;  Urotropin;  Cystogen;  Aminoform;  Formin. 

It  forms  colorless,  lustrous  crystals,  having  a  slight  alkaline 
taste.    It  is  soluble  in  1.5  parts  of  water  and  10  parts  of  alcohol. 

Average  Dose. — 4  grains  (0.25  Gm.). 

Citarin;  Sodium  AnJiydrometJiylen  Citrate.  It  is  a  white  gran- 
ular powder,  having  a  faintly  saline  taste  and  a  slightly  acid  re- 
action. It  is  soluble  in  1.5  parts  of  water.  In  the  presence  of 
alkalis  it  is  split  up  in  formaldehyd  and  sodium  citrate.  Average 
dose,  15  grains  (1  Gm.). 

Atophan;  Phenyl-quinolin-carboxylic  Acid. 

It  appears  in  small  colorless  crystals,  insoluble  in  water,  but 
readily  soluble  in  alkalies,  and  hot  alcohol.  It  has  a  slightly  bit- 
ter taste.  It  is  best  borne  when  administered  simultaneously  with 
60  grains  (4  Gm.)  of  sodium  bicarbonate.  Average  dose,  71/2 
grains  (0.5  Gm.)  three  to  four  times  a  day,  suspended  in  large 
quantities  of  water. 


ANTIPYRETICS  43 1 

PiPERAZIN  ;    DiETHYLENEDIAMIN. 

It  forms  colorless,  lustrous,  very  hygroscopic  crystals,  which  are 
very  readily  soluble  in  water,  forming  strongly  alkaline,  but  not 
caustic,  solutions. 

Average  Dose. — 7i/^  grains  (0.5  Gm.). 

Lycetol,  a  piperazin  tartrate,  and  sidonal,  a  piperazin  quinate, 
have  been  lately  introduced  as  substitutes  for  pure  piperazin. 

For  Gouty  Pericementitis. 

B     Hexamethylenaminaa  S  ss   (16.0  Gm.) 

Colchicinse  gr.  ss   (0.03  Gm.) 

M.  f.  tablet.  No.  Lx. 

Sig. :    A  tablet  dissolved  in  a  tumblerful  of  water  five  times 
daily. 


IJ     Atophani  gr.  viij   (0.5  Gm.) 

Tablet.  No.  xij. 

Sig.:     A  tablet  dissolved  in  a  tumblerful  of  water  3  or  4 
times  daily. 

ANTIPYRETICS. 

Antipyretics  or  antifehriles,  both  meaning  against  fever,  are 
remedies  employed  for  the  purpose  of  reducing  increased  bodily 
temperature.  They  incidentally  act  as  sedatives  and  anodynes, 
and  are  frequently  employed  in  dentistry  to  relieve  neuralgia; 
hence  they  are  sometimes  referred  to  as  antineuralgics  or  anti- 
nervins. 

The  normal  temperature  of  man  is  comparatively  constant — 
that  is,  the  changes  vary  within  a  very  narrow  limit.  Normally, 
the  body  temperature  ranges  between  98.5°  and  99.5°  F.  (36.9° 
and  37.4°  C).  The  external  air  has  very  little  influence  on  the 
temperature  of  the  human  body.  It  is  immaterial  whether  we 
are  exposed  to  the  broiling  sun  of  the  equator  (120°  F.,  49°  C.) 
or  to  the  icy  cold  of  Spitzbergen  (—40°  F.,  — 40°  C.)  ;  our  in- 
ner temperature  of  99°  F.  (37.3°  C.)  remains  unaltered.  The 
regulation  of  the  body  temperature  is  controlled  by  specific  nerves, 
although  we  are  able  by  suitable  protection — heavy  or  light  cloth- 
ing, warm  rooms  or  shady,  airy,  open  spaces — to  materially  in- 
fluence the  radiation   of  bodily   heat.     The  regulation   of  heat- 


432  PH  ARM  A  CO-THERAPEUTICS 

producing  foodstuffs  is  of  prime  importance;  cold  climates  require 
easily  combustible  fats  or  other  carbohydrates,  while  in  the  tropics 
we  instinctively  avoid  a  steaming  dish  of  "pork  and  beans,"  A 
rise  of  temperature  of  the  surromidings  causes  dilation  of  the 
peripheral  vessels,  which  forces  the  warm  blood  to  the  surface  to 
be  cooled  off,  and  the  ready  evaporation  of  perspiration  from  an 
increased  action  of  the  sweat  glands  cools  the  body  surface.  The 
combined  process  of  heat  production  and  regulation  is  based  on 
physiologic,  chemic,  and  physical  laws.  An  abnormally  increased 
heat  produced  by  physical  exertion  and  unfavorable  external  con- 
ditions— high  heat,  humid  atmosphere,  etc. — may  lead  to  over- 
heating of  the  body;  104°  F.  and  even  as  high  as  113°  F.  (40° 
to  45°  C.)  have  been  observed  in  sunstrokes. 

A  rise  in  the  body  temperature  is,  in  the  majority  of  cases,  the 
symptom  of  fever,  provided  this  higher  temperature  is  of  a  fairly 
constant  nature.  Fever  is  not  a  disease,  but  a  pathognomonic  sign 
of  disturbance  of  the  equilibrium  of  the  organism  as  a  whole.  In 
most  cases  fever  is  the  result  of  infection,  although  traumatic  dis- 
turbances— subcutaneous  fractures — may  cause  a  so-called  aseptic 
fever,  which  in  its  production  is  somewhat  analogous  to  an  aseptic 
suppuration.  The  causes  of  the  increased  temperature  in  fever 
have  given  rise  to  various  theories;  the  present  consensus  of  opin- 
ions seems  to  point  to  the  fact  that  fever  is  an  indication  that  the 
centers  of  heat  regulation  are  gauged  to  a  higher  standard  than 
that  which  is  normally  present  in  the  body.  Accepting  this 
hypothesis,  we  may  explain  the  causative  factors  of  fever  as  fol- 
lows: Certain  pyretogenic  (fever  producing)  chemic  substances 
act  on  the  centers  of  heat  regulation  by  interfering  with  the  normal 
equilibrium  of  heat  production  and  heat  radiation,  and  as  a  con- 
sequence these  centers  are  shifted  to  a  higher  plane  and  a  higher 
constant  body  temperature  is  the  result.  The  true  antipyretics 
act  on  the  higher  gauged  centers,  and  their  influence  causes  the 
centers  to  return  to  their  normal  position.  External  influence  on 
heat  production  and  heat  regulation  do  not  interfere  with  the 
action  of  the  true  antipyretics.  Indirect  antipyretics — quinin, 
salicylic  acid,  etc. — as  they  are  sometimes  called,  influence  the  heat 
centers  partially,  but  they  act  principally  on  heat  production  and 
heat  radiation. 

The  pathologic  significance  of  fever  has  kept  pace  with  the 
spirit  dominating  medical  practice.     At  one  time  it  was  thought 


ANTIPYRETICS  433 

that  fever  was  a  dangerous  disease  and  had  to  be  cured,  and,  again, 
it  was  looked  upon  as  an  expression  of  vis  medicatrix  natures,  a 
view  which  is  at  present  favored  by  leading  clinicians.  Conse- 
quently fever  should  not  be  "treated"  immediately.  If,  however, 
the  organism,  in  its  effort  to  combat  an  infection,  produces  an  ab- 
normal high  temperature,  it  is  the  duty  of  the  sensible  practitioner 
to  administer  suitable  antipyretics — to  coax  nature  to  return  to  her 
normal  functions.  Fever  may  damage  the  organism  in  various 
ways.  Abnormal  high  temperature  is  imminently  dangerous  to 
the  heart,  and,  furthermore,  a  high  temperature  causes  increased 
metabolism,  with  loss  of  strength,  as  the  destroyed  albumin  mole- 
cule can  not  be  replaced  with  sufficient  rapidity.  The  increased 
temperature  is  accompanied  by  a  disturbed  psyche ;  the  patient  is 
fidgety,  and  sleeplessness  and  restlessness  cause  the  loss  of  much 
valuable  vital  resistance. 

The  action  of  antipyretics  in  general  is  confined  to  the  central 
nervous  system;  they  reduce  the  temiperature  and  incidentally  act 
as  sedatives  and  anodynes. 

QuiNiN  Sulphate;  Quinine  Sulphas,  U.  S.  P.,  B.  P.;   (C20H24 
02)2-H2S04-|-7H20;     Sulphate    de    Quinine,    F.;    Schwefel- 

SAURES    ChININ,    G. 

Source  and  Character.— It  is  the  sulphate  of  the  alkaloid  qui- 
nin,  obtained  from  the  various  species  of  Cinchona.  It  appears 
in  white,  silky,  light,  flexible  crystals,  or  hard  prismatic  needles, 
colorless,  and  having  a  persistent  bitter  taste.  It  absorbs  moisture 
from  the  air.  It  is  soluble  in  720  parts  of  water,  86  parts  of  al- 
cohol, and  36  parts  of  glycerin ;  diluted  acids  increase  its  solubility 
in  water.  It  is  incompatible  with  ammonia,  alkalies,  lime  water, 
tannin,  potassium  iodid,  etc. 

Average  Dose. — 4  grains  (0.25  Gm.). 

Therapeutics.— Quinin  is  the  sovereign  remedy  in  malaria ;  here 
it  acts  as  a  specific.  It  is  a  protoplasm  poison;  administered  in 
therapeutic  doses,  it  destroys  the  causative  factors  of  malaria,  the 
Plasmodia  7nalari(B,  without  materially  altering  the  protoplasm  of 
the  cells  of  the  host.  Quinin  should  be  administered  three  to  four 
hours  before  the  typical  malarial  attack  is  manifested,  so  as  to 
allow  sufficient  time  for  its  absorption.  It  is  a  prompt  prophy- 
lactic against  this  disease.    Its  action  as  an  antiseptic  on  bacteria 


434  PHARMACO-THERAPEUTICS 

or  their  spores  is  very  weak.  It  inhibits  the  migration  of  leucocytes, 
and  for  this  reason  Binz  and  Helmholz  recommended  it  at  one 
time  as  an  antiphlogistic.  Its  local  application  based  on  this  sup- 
position, was  much  lauded  in  the  treatment  of  pj^  orrhea  alveolaris. 
While  it  is  true  that  quinin  inhibits  the  migration  of  the  white 
blood  corpuscles,  and,  as  a  consequence,  retards  the  typical  symp- 
toms of  inflammation,  it  increases  the  spreading  of  the  infection. 
When  inflammation,  which  is  nature's  curative  agent  against  in- 
fection, is  checked,  the  infection  progresses  unhindered  on  its  path 
of  destruction.  Quinin  acts  on  the  central  nervous  system  as  an 
anodyne;  it  reduces  the  irritability  of  the  sensory  nerves,  and  is 
used  as  an  antineuralgic.  In  influenza  and  in  septicemia  it  de- 
serves to  be  recommended.  Quinin  is  best  administered  in  loose- 
filled  capsules,  in  pills,  or  suspended  in  syrup  of  yerba  santa.  In- 
jected locally  in  the  readily  soluble  form  of  quinin  and  urea  hydro- 
chlorid  it  acts  as  a  local  anesthetic.     (See  Local  Anesthetics.) 

Aside  from  quinin  sulphate,  quite  a  large  number  of  other  quinin 
salts,  artificial  alkaloids,  and  a  tincture  and  infusion  of  cinchona 
bark  are  medicinally  employed. 

Acetylsalicylic  acid,  known  as  aspirin,  and  in  a  recent  modifica- 
tion as  novaspirin,  is  a  prompt  and  valuable  antipyretic  and  ano- 
dyne. It  is  specially  recommended  in  neuralgic  and  rheumatic 
pain  about  the  face  and  head.  It  is  only  slightly  soluble  in  water, 
but  readily  soluble  in  alcohol.  It  is  best  administered  in  tablet 
form.    Average  dose,  7I/2  grains  (0.5  Gm.). 

Salicylic  acid  and  its  many  salts  and  synthetic  substitutes — 
glycosal,  salophen,  salaeetol — have  been  referred  to  under  salicylic 
acid. 

Antipyrin  ;  Antipyrina,  U.  S.  P. ;  Phenazonum,  B.  P. ; 
C11H12N2O ;  Analgesixe,  Antipyrine,  F.  ;  Antipyrin,  G. 

Source  and  Character. — It  is  a  derivative  of  pyrazolon,  and 
forms  a  colorless,  almost  odorless,  crystalline  powder,  having  a 
slightly  bitter  taste.  It  is  soluble  in  less  than  1  part  of  water,  and 
1  part  of  alcohol.  It  is  incompatible  with  acids,  alkalies,  tannin, 
salicylates,  etc. 

Average  Dose. — 4  grains  (0.25  Gm.). 

Therapeutics. — Antipyrin  is  a  general  antipyretic  and  anodyne. 
It  acts  on  the   central  nervous  system,   and   reduces   the  higher 


ANTIPYRETICS  435 

gauged  centers  of  heat  regulation  to  their  normal  position.  It  is  an 
effective  remedy  in  neuralgia,  migraine,  lumbago,  and  sciatica.  It 
should  be  given  in  strong  doses  from  4  to  8  grains  (0.25  to  0.5 
Gm.),  dissolved  in  water  or  in  gelatin  capsules.  Some  persons 
show  a  distinct  idiosyncrasy  to  this  drug,  which  is  often  accom- 
panied by  skin  eruptions. 

A  number  of  other  pyrazolon  derivatives  have  appeared  within 
the  last  decade,  of  which  migrainin,  trigemin,  pyramidon  salicy- 
late and  salipyrin  are  the  best  known  representatives.  The  lat- 
ter is  especially  lauded  in  facial  neui-algia  and  the  various  forms 
of  toothache,  and  is  given  in  7i/^-grain  (0.5  Gm.)  doses. 

Acetanilid;  Acetanilidum,  U.  S.  p.,  B.  P.;  CgHgNO;  Anti- 

FEBRINE,   AcETANILIDE,   F.  ;   AnTIFEBRIN,   G. 

Source  and  Character. — It  is  the  monacetyl  derivative  of  ani- 
lin.  It  is  a  colorless,  crystalline  powder,  odorless,  and  having  a 
slightly  burning  taste.  It  is  soluble  in  180  parts  of  water,  2.5  parts 
of  alcohol,  and  in  chloroform  and  ether.  It  is  incompatible  with 
nitrous  ether,  bromids,  iodids,  phenol,  resorcinol,  and  thymol. 

Average  Dose. — 3  grains  (0.2  Gm.). 

Therapeutics. — Acetanilid  acts  on  the  central  nervous  system 
as  a  powerful  anodyne.  In  large  doses  it  acts  as  a  blood  poison  by 
forming  methemoglobin,  which  manifests  itself  in  pronounced 
cyanosis.  Acetanilid  forms  the  base  of  many  *  *  headache ' '  powders 
and  of  many  copyrighted  pharmaceutic  preparations  generically 
known  as  "coal  tar  derivatives."  Many  cases  of  poisoning  result- 
ing from  the  indiscriminate  use  of  these  compounds  are  on  record. 
Acetanilid  is  a  prompt  antipyretic ;  it  is  best  administered  in  pow- 
der (capsules,  tablets,  or  cachetes),  in  alcoholic  solutions,  or  as  the 
compound  powder  of  acetanilid,  pulvis  acetanilidum  compositus. 
The  average  dose  of  the  latter  is  7>^  grains  (0.5  Gm.). 

AcetpJienetidin;  AcetpJienetidinum,  U.  S.  P. ;  Phenacetinum,  B. 
P. ;  C10II13NO2 ;  PJienacetin.  It  is  a  derivative  of  anilin  and  closely 
related  to  acetanilid,  but  it  is  less  poisonous  than  the  latter.  It 
is  a  white  crystalline  powder,  having  no  odor  or  taste.  It  is  sol- 
uble in  925  parts  of  water  and  12  parts  of  alcohol.  It  is  best 
administered  in  powder  form.  It  is  a  prompt  antipyretic  and  ano- 
dyne, and  its  toxic  side  action,  as  compared  with  acetanilid,  is 
decidedly  less.    Average  dose,  5  grains  (0.3  Gm.). 


436  PHARMACO-THERAPEUTICS 

A  number  of  other  anilin  derivatives  are  known — lactophenin, 
phenocoll,  kryofin — and  are  given  in  about  the  same  doses  as 
phenacetin,  but  apparently  do  not  possess  any  therapeutic  advan- 
tages over  the  latter. 

For  Facial  Neuralgia. 

IJ     Phenacetin.  3  j  (4.0  Gm.) 

M.  f.  pulv.  No.  viij 
Sig.:     A  powder  every  three  hours. 


ORGANO  AND  SERUM  THERAPY. 
Organo  Therapy. 

The  immense  strides  which  have  been  made  within  the  last  few 
decades  in  general  therapeutics  have  occasioned  the  utilization  of 
animal  tissues  or  their  products  for  medicinal  purposes.  Their 
application  is  known  as  organo  therapy. 

The  use  of  animal  drugs  for  medicinal  purposes  is  probably  as 
old  as  the  history  of  the  human  race;  organic  secretions,  parts  of 
the  animal,  and,  in  some  instances,  the  whole  animal  have  always 
played  with  our  remotest  ancestors  a  more  or  less  important  role 
in  curing  diseases.  The  use  of  testicles  against  impotence,  the  gall 
of  snakes,  birds,  fishes,  etc.,  in  diseases  of  the  brain,  or  the  bile  of 
a  snake  or  scorpion  are  accredited  with  high  curative  power  in 
most  of  the  medical  records  of  the  early  civilized  nations  of  the  old 
world.  The  tendency  of  medicinally  applying  organic  prepara- 
tions seems  to  center  in  the  natural  desire  to  cure  a  diseased  organ 
by  an  extraction,  decoction,  tincture,  or  similar  preparation  of  the 
same  organ  or  its  secretion  obtained  from  some  animal.  So,  then, 
we  find  that  in  diseases  of  the  urinary  organs  the  drinking  of 
urine,  in  the  bite  of  a  rabid  dog  the  stewed  gall  of  a  dog  affected 
with  hydrophobia,  and  in  the  presence  of  intestinal  worms  decoc- 
tions of  worms  in  oils  were  highly  lauded.  The  empiric  evolution 
of  therapeutic  applications  was  apparently  based  on  the  supposi- 
tion to  cure  like  things  by  like,  a  doctrine  which  many  centuries 
later  was  adopted  as  simUia  similihus  curantur  by  the  homeo- 
pathic school.  Modern  organo  therapy  received  its  scientific  in- 
centive from  the  work  of  BroAvn-Sequard  by  the  presentation  of 
his  epoch-making  essay  relative  to  the  use  of  the  extract  of  testicles 
before  the  French  Academy  of  Science  in  1869.     He  based  hip 


ORGANO   AND   SERUM   THERAPY  437 

conception  on  "internal  secretions,"  which,  as  he  claims,  continu- 
ously supply  the  blood  and  lymph  stream  with  certain  materials 
intended  to  perform  important  functions  in  the  cycle  of  living 
processes.  Claude  Bernhard  had  called  attention  to  the  secretion 
of  the  ' '  ductless  glands, ' '  as  well  as  to  certain  other  glands,  which 
produce  specific  bodies.  These  bodies  are  probably  in  the  nature 
of  ferments,  and  they  are  absolutely  essential  for  the  maintenance 
of  bodily  functions.  According  to  Hansemann  it  seems  that  an 
altruistic  relationship  exists  between  the  various  types  of  tissue 
cells.  One  type  of  cells  will  undertake  the  work  of  other  types, 
and,  vice  versa,  these  other  types  will  do  the  work  of  the  one  type 
of  cells.  This  conception  is  closely  allied  to  the  theory  of  Fraser 
regarding  the  formation  of  antitoxins  in  the  bodies  of  those  ani- 
mals which  produce  a  definite  poison  that  is  fatal  to  other  animals, 
but  not  to  themselves. 

The  thyroid  gland  is  a  typical  representati^'e  of  a  ductless  gland. 
The  administration  of  the  dried,  powdered  gland  or  its  extract  in 
diseases  which  are  connected  in  one  way  or  another  with  this 
gland — myxedema,  goiter,  cretinism — has  produced  most  remark- 
able results.  Its  administration  must  be  continued  for  a  long 
period,  often  throughout  life,  to  prevent  relapses.  The  thyroid 
gland  contains  in  its  cell  a  peculiar  globulin  known  as  thyroglob- 
ulin.  The  active  constituent  of  this  body  seems  to  be  an  organic 
form  of  iodin — iodothyrin.  Its  greatest  influence  is  manifested 
by  its  action  of  metabolism ;  it  increases  the  waste  of  proteins  and 
the  oxidation  of  fats  in  the  body,  with  an  unusually  large  amount 
of  urine  excretion. 

The  extract  of  the  testicles,  or  an  alkaloid  obtained  therefrom 
and  known  as  spermin,  is  recommended  in  cases  where  the  dimin- 
ished sexual  powers  call  for  a  stimulation  of  their  activity.  The 
extract  of  bone  marrow  and  of  the  spleen  are  recommended  in  per- 
nicious anemia  to  increase  the  formation  of  erythroblasts.  The 
thymus  gland  or  its  extract  has  been  advised  in  exophthalmic 
goiter.  An  extract  of  the  pituitary  body  has  been  advocated  in 
diseases  associated  with  hypophysis.  Fresh  and  purified  ox  gall  is 
employed  as  a  cholagogue,  purgative,  and  intestinal  antiseptic. 
The  extract  of  the  suprarenal  gland  or  its  alkaloid,  epinephrin. 
has  been  suggested  in  Addison's  disease,  a  peculiar  affection  of 
these  glands.  The  very  remarkable  property  of  epinephrin  to  in- 
crease the  blood  pressure,  and  incidentally  cause  local  anemia  when 


438  PHARMACO-THERAPEUTICS 

applied  locally  or  Injected  hypodermically,  is  referred  to  under 
Suprarenal  Glands. 

Serum  Therapy. 

The  introduction  of  bacteriology  into  general  medicine  has  ex- 
ercised a  most  powerful  influence  on  the  biologic  conception  of 
infectious  diseases.  The  discovery  of  specific  organisms  as  the 
causative  factors  of  specific  infectious  diseases  has  completely 
changed  the  therapeutic  application  of  remedial  measures  by  creat- 
ing a  definite  method  of  treatment  known  as  serum  therapy  or  as 
biologic  therapeutics. 

The  bacteria  of  certain  infectious  diseases  invade  the  body  only 
in  definite  places^ — as  diphtheria  in  the  throat — but  nevertheless 
the  reaction  of  the  entire  body  to  this  disease  indicates  that  specific 
products  of  these  causative  factors  must  have  reached  the  blood. 
Infection  is  more  or  less  always  accompanied  by  intoxication;  the 
latter  is  the  result  of  the  absorbed  specific  poisons.  The  isolation 
of  these  poisons  (toxins  of  bacterial  origin,  especially  from  putre- 
fying protein  substances)  led  to  the  discovery  of  ptomains — cadav- 
erine,  putrescine,  neuridine,  etc.  These  peculiar  alkaloid-like  bodies 
are,  however,  not  the  specific  cause  of  the  disease,  as  it  was  soon 
found  that  the  real  poisons  are  ferment-like  bodies  known  as  bac- 
terial toxins.  These  compounds  are  very  powerful  poisons,  and 
the  smallest  quantity  will  produce  toxic  symptoms  which  are  not 
equaled  in  their  intensity  by  any  other  known  substance.  The 
toxins  differ  from  other  poisons  in  so  far  as  they  require  a  certain 
period  of  incubation  before  they  develop  their  powerful  destruc- 
tion, and  they  are  not  necessarily  equally  poisonous  to  all  animals. 

When  an  animal  is  inoculated  with  a  certain  pathogenic  organ- 
ism without  producing  specific  symptoms  of  the  disease,  it  is  said 
to  be  immune.  This  peculiar  condition  is  referred  to  as  natural 
immunity  when  the  animal  does  not  react  to  the  inoculated  organ- 
ism without  a  preliminary  preparation,  and  as  acquired  immunity 
when  it  does  not  react  after  it  has  passed  through  a  mild  attack  of 
the  disease,  or  when  it  is  artificially  prepared  against  it  by  injec- 
tion of  certain  substances.  Immunity  is  the  result  of  the  action  of 
substances  present  in  the  blood  of  the  individual — the  alexins.  If 
a  person  has  passed  through  a  mild  attack  of  measles,  smallpox, 
scarlatina,  etc.,  he  is  usually  immune  for  a  shorter  or  longer  period 
against  a  future  attack  of  these  diseases.     "Weak,  attenuated  eul- 


ORGANO   AND   SERUM    THERAPY  439 

tures  of  bacteria,  when  inoculated  into  the  body,  will  accomplish 
the  same  results.  Attenuated  cultures  may  be  prepared  by  ex- 
posing the  ordinary  virulent  pure  cultures  to  light,  heat,  chemic 
agents,  etc.,  or  by  passing  them  through  the  body  of  an  animal 
which  is  especially  rich  in  alexins.  The  principle  is  based  on  the 
original  empiric  vaccination  with  cowpox  against  smallpox  as  in- 
augurated by  Jenner  in  1796.  After  an  active  immunization  the 
blood  is  found  to  contain  specific  antibodies,  which  act  against 
the  invading  bacteria  or  their  poisonous  products  in  the  nature  of 
an  antidote.  These  antibodies  are  substances  of  an  albuminous 
character,  and  are  relatively  very  weak  compounds,  especially  to 
heat,  cold,  light,  chemicals,  etc.  It  has  been  found  that  when 
blood  obtained  from  animals  which  are  especially  rich  in  these 
antibodies — that  is,  blood  from  animals  which  are  actively  im- 
munized^is  injected  into  other  animals  which  have  not  been  pre- 
viously treated,  these  latter  animals  will  become  immune  against 
the  specific  organism.  This  form  of  immunization  produces  pas- 
sive immunity.  Passive  immunity  lasts  only  a  short  time — about 
three  weeks  in  diphtheria — while  active  immunity  may  last  the 
entire  life.  Passive  immunization  is  sometimes  employed  as  a 
prophylactic  against  a  specific  disease,  but  principally  as  a  cura- 
tive agent  in  the  early  stages  of  infectious  diseases.  The  injected 
antibodies  will  attack  the  toxins  present  in  the  blood ;  they  act  as 
true  curative  agents,  and  are  known  as  antitoxic  sera.  The  anti- 
toxins may  act  in  two  ways — they  may  be  specific  antibodies  against 
a  specific  bacterium  (always  against  only  one  species),  or  they  may 
act  as  antibodies  against  the  toxins  present  in  the  blood  of  the 
infected  individual.  The  antitoxins  are  true  antidotes;  they  com- 
bine with  the  toxins  somewhat  in  the  same  manner  as  an  acid  will 
neutralize  an  alkali.  Aside  from  the  explanation  regarding  the 
action  of  antitoxins  and  other  bactericidal  substances  as  presented 
by  Behring,  Kitasato,  Nuttall,  Pfeiffer,  Ehrlich,  and  others,  the 
phagocytes  have  been  held  responsible  by  Metchnikoff  for  the  mech- 
anism of  immunity.  He  claims  that  the  phagocytes  are  certain 
white  blood  corpuscles,  Avhich  act  as  digesters,  scavengers,  and 
chief  defenders  against  the  invading  bacteria.  "The  diapedesis  of 
the  white  blood  corpuscles,  their  migration  through  the  vessel 
wall  into  the  cavities  and  tissues,  is  one  of  the  principal  means 
of  defense  possessed  by  an  animal.  As  soon  as  the  infective 
agents  have  penetrated  into  the  body,  a  whole  army  of  white  cor- 


440  PHARMACO-THERAPEUTICS 

puscles  proceeds  toward  the  menaced  spot,  there  entering  into  a 
struggle  with  the  micro-organism. '  '^  The  action  of  the  phagocytes 
may  be  intensified  or  diminished  in  various  ways.  To  accomplish 
this  purpose  certain  other  substances  present  in  the  blood  of  the 
individual  nrust  be  determined.  These  substances  are  knoAvn  as 
opsonins,  and  Wright  has  devised  an  ingenious  method  for  de- 
termining the  amount  of  opsonins  present  in  the  individual,  or, 
as  he  refers  to  it,  to  establish  the  opsonic  index.-  The  opsonins 
(to  prepare  for  food)  are  substances  which,  in  some  unknown 
manner,  act  on  the  bacteria  and  prepare  them  for  digestion  by 
the  phagocytes.  The  opsonic  index  indicates  whether  the  opsonic 
substances  present  in  the  blood  are  above  or  below  the  normal 
standard.  The  treatment  of  infectious  diseases  by  opsonins  has 
found  many  admirers  among  clinicians,  and  it  has  been  recently 
introduced  by  Goadby^  for  the  treatment  of  pyorrhea  alveolaris. 
The  technic  of  preparing  the  opsonic  index  and  the  treatment  of 
pyorrhea  with  opsonins  has  been  clearly  set  forth  by  Heeker.* 

A  recent  interesting  hypothesis  regarding  the  existence  of  bac- 
terial substances  in  the  body  fluids  has  been  made  by  Ehrlich,  and 
is  known  as  side-chain  or  receptor  theory.  While  the  doctrine  of 
reception  is  largely  an  assumption,  it  is  nevertheless  a  most  in- 
genious attempt  to  explain  the  action  of  antitoxic  serum,  and  it 
may  aid  as  an  incentive  for  further  research  in  this  interesting 
field  of  therapeutics. 

The  antitoxic  sera  are  principally  administered  by  hypodermic 
injection ;  they  enter  the  blood  and  combine  directly  with  toxins  of 
the  disease,  thereby  destroying  poison.  The  toxins  of  infectious 
disease  remain  only  a  very  short  time  in  the  circulation.  They 
usually  combine  more  or  less  quickly  with  the  protoplasm  of  such 
cells  for  which  apparently  they  possess  an  affinity,  and  then  they 
are  reached  only  with  difficulty,  or  not  at  all,  by  the  antitoxins; 
hence  the  importance  of  an  early  injection  of  the  latter  is  ap- 
parent. 

The  various  sera,  bacterial  vaccines,  and  similar  biologic  prod- 
ucts are  at  present  manufactured  on  a  large  scale.  To  insure  uni- 
formity of  these  products,   and  to  prevent  their  indiscriminate 


*  Metchnikoff :  Immunity,  1905. 

*  Wright:  Proceedings  of  the  Royal  Society  of  England,   1903 

*  Goadby:  British  Dental  Journal,  1907,  p.  885. 

*  Heeker:  Pyorrhea  Alveolaris,  St.  Louis,  1915. 


ORGANO  AND   SERUM   THERAPY  441 

compounding  by  the  inexperienced,  the  United  States  government, 
after  a  careful  investigation  of  the  respective  laboratories,  has 
licensed  certain  manufacturers  to  prepare  these  various  biologic 
products. 

An  antitoxic  serum  against  diphtheria,  which  has  been  used 
with  very  gratifying  results,  a  serum  against  tetanus,  and  various 
sera  against  tuberculosis  are  universally  employed  at  present  in 
general  medicine.  Of  the  many  vaccines,  those  of  the  staphylo- 
cocci, streptococci,  gonococci,  lactic  acid  bacilli,  and  a  few  others 
are  the  principal  representatives.  The  pus  vaccines  and  a  lactic 
acid  culture  known  as  massolin  are  used  at  present  in  the  treat- 
ment of  dental  lesions.  The  pus  vaccines  are  employed  hypo- 
dermdcally,  according  to  "Wright's  method,  after  establishing  the 
opsonic  index,  while  massolin  is  used  with  a  spray  in  chronic 
antral  diseases.  For  the  latter  purpose  it  is  recommended  to  in- 
ject the  lactic  acid  culture  in  1-cubic-centimeter  doses  with  an 
atomizer  every  other  day  into  the  diseased  sinus  until  pus  forma- 
tion ceases.  Based  on  the  same  principle,  sour  milk  has  been  used 
for  the  above  purposes  by  Lohmann  some  years  ago.  A  culture 
of  the  bacillus  pyocyaneus,  known  as  pyocyanase,  is  recommended 
by  the  above  author  in  the  local  treatment  of  pyorrhea  alveolaris. 
The  application  is  simple:  After  the  preliminary  cleansing  of 
the  mouth  and  the  remx,oval  of  calcareous  deposits  from  the  teeth, 
etc.,  pyocyanase  is  injected  into  the  pus  pockets,  and  the  latter  are 
covered  with  an  unctuous  paste  to  temporarily  prevent  its  wash- 
ing away  by  the  saliva.  The  remedy  may  be  applied  once  or  twice 
a  day,  according  to  the  severity  of  the  case,  until  pus  formation 
ceases. 

The  application  of  serum  therapy  in  dentistry  is  as  yet  in  its 
infancy;  the  results  obtained  with  biologic  therapeutics  in  gen- 
eral medicine  are,  however,  very  encouraging,  and  it  is  but  reason- 
able to  apply  the  same  principle  in  diseases  of  the  oral  tissues. 


PART  III 
PHYSICAL  THERAPEUTICS 


ARTIFICIAL  HYPEREMIA 

In  the  treatment  of  diseases  a  variety  of  methods  and  measures 
are  employed  as  remedial  agents  which  can  not  be  properly  classi- 
fied as  drugs  if  we  restrict  the  latter  term  to  organized  substances 
which,  when  introduced  into  the  living  body,  counteract  disease. 
A  remedy,  in  the  broadest  sense  of  the  term,  is  anything  which 
cures,  palliates,  or  prevents  disease,  and,  consequently,  thera- 
peutics comprise  the  utilization  of  all  means  and  methods  which 
are  employed  for  the  purpose  of  relieving  the  sick  and  favorably 
modifjdng  the  evolution  of  disease — i.e.,  the  art  of  healing.  In 
addition  to  the  use  of  drugs  and  surgical  procedures,  a  number  of 
mechanical  and  physical  forces  are  employed,  which,  for  the  want 
of  a  better  term,  are  classified  as  physical  therapeutics,  and  they 
include  Bier's  artificial  hyperemic  treatment,  massage,  heat,  cold, 
light,  electricity,  etc. 

The  pathologic  studj'  of  infectious  diseases  and  their  treatment 
has  been  completely  revolutionized  within  the  last  few  decades. 
The  primary  cause  of  this  change  may  be  attributed  to  the  re- 
markable development  of  the  science  of  bacteriolog5%  and  its  in- 
troduction into  biology  marks  a  conspicuous  epoch  in  the  scientific 
progress  of  medicine.  Louis  Pasteur  was  the  founder  of  bacteri- 
ologj'.  Joseph  Lister  introduced  it  as  "antisepsis"  into  surgery, 
and  when  Robert  Koch,  in  1876,  brought  forward  convincing  evi- 
dence that  certain  specific  micro-organisms  were  the  cause  of  cer- 
tain specific  diseases,  the  old  superstitious  belief  in  miasms,  con- 
tagion, and  spontaneous  generation  received  its  death  blow.  Bac- 
teriologic  research  revealed  the  important  fact  that  the  body  fluids 
possess  the  power  of  destroying  or  neutralizing  poisons  which 
enter  the  body  from  Avithout.  It  is  rather  remarkable  that  the 
developmental  study  of  diseases  selected  the  most  difficult  ones 

442 


ARTIFICIAL   HYPEREMIA  443 

—anthrax,  hydrophobia,  diphtheria,  tuberculosis,  etc.— for  its  in- 
itial investigation,  while  ordinary,  simple  infection,  until  lately, 
has  been  grossly  neglected.  Recently  certain  sera  have  been  pre- 
pared for  the  purpose  of  combating  the  invasion  of  the  pus  pro- 
ducing micro-organisms,  and  in  many  cases  they  have  given  en- 
couraging results. 

Within  recent  years  a  new  remedial  measure  has  been  intro- 
duced into  therapeutics  for  the  purpose  of  combating  infectious 
diseases  which  is  so  surprisingly  simple,  and  yet  so  very  definite 
in  its  final  result,  that  one  can  only  wonder  why  it  was  not  dis- 
covered a  long  time  ago.  The  object  of  the  treatment  consists  in 
the  increased  utilization  of  the  natural  resources  which  the  body 
possesses  in  the  fight  against  local  infection,  and  is  known  at  pres- 
ent as  the  hyperemic  treatment  of  Bier.  Bier  founded  his  con- 
ception of  this  treatment  on  observations  which  he  had  made  in 
the  clinic  of  Rokitansky  in  Vienna.  He  had  repeatedly  pointed 
out  that  a  lung  with  a  chronic  obstructive  h3'peremia  resulting 
from  some  valvular  insufficiency  of  the  heart  would  not,  in  the 
great  majority  of  cases,  be  attacked  by  tuberculosis.  On  logical 
reasoning  Bier  applied  the  same  principle  with  surprisingly  good 
results  in  the  treatment  of  chronic  infections  of  the  joints.  In 
due  time  the  technic  of  this  treatment,  depending  largely  upon 
the  construction  of  suitable  apparatus,  had  to  undergo  many  modi- 
fications; but,  even  Avith  the  remarkable  increase  of  the  scope  of 
its  utilization  it  is  still  employed  by  comparatively  few  practi- 
tioners. 

According  to  Meyer-Schmieden,^  the  aim  of  Bier's  hyperemic 
treatment  is  to  bring  about  "the  increase  of  the  beneficial  inflam- 
matory hyperemia  resulting  from  the  fight  of  the  living  body 
against  invasion,"  and  the  most  important  principle  underlying 
this  treatment  is  that  "the  blood  must  continue  to  circulate — there 
nxust  never  be  a  stasis  of  the  blood."  In  German,  Bier  calls  his 
treatment  StauiingsJiyperdviie,^  a  term  which  expresses  the  cause 
as  well  as  the  effect.  Staining,  translated  into  English,  means 
stowing.  Many  interpretations  of  the  German  term  have  been  at- 
tempted— as  congestive,  induced,  artificial-active  and  artificial-pas- 
sive, or  artificial-arterial  and  artificial-venous  hyperemia,  and 
sometimes,  although  an  absolutely  false  translation,  stasis  hyper- 

»  Willy  Meyer-Schmieden:  Bier's  Hyperemic  Treatment,  1908. 
»Bier:   Hyperamie  als  Heilmittel.   1903. 


444  PHYSICAL   THERAPEUTICS 

emia.  As  yet  no  definite  term  has  been  adopted  by  tlie  English- 
speaking  profession,  and,  as  we  have  so  far  followed  the  trend  of 
thought  as  outlined  by  Meyer-Sehmieden,  we  adopt  their  sugges- 
tion and  use  the  term  "obstructive  hyperemia"  in  the  following 
pages. 

Before  entering  into  the  philosophic  conception  of  obstructive 
hyperemia  according  to  Bier,  it  is  probably  well  to  rehearse  in  a 
preliminary  way  the  significance  of  inflammation  from  a  modern 
pathologic  point  of  view. 

At  present  it  is  generally  conceded  that  inflammation  is  not  a 
disease,  but  that  it  is  the  local  defense  of  the  tissues  against  an 
injury,  manifesting  itself  by  more  or  less  pronounced  symptoms — 
as  redness,  heat,  swelling,  pain,  and  impaired  function.  The  most 
important  changes  occur  in  the  blood  vessels,  which  are  distended 
by  an  increased  influx  of  blood  that  is  very  quickly  displaced  by 
a  retarded  afflux.  The  white  corpuscles  conglomerate  in  bunches 
near  the  vessel  wall,  especially  in  the  veins  and  capillaries,  while 
the  red  blood  corpuscles  keep  more  to  the  center  of  the  blood 
stream.  The  leucocytes  and  the  lymphocytes  now  pass  between 
the  endothelial  cells  through  the  vessel  walls  of  the  veins  and  of 
the  capillaries,  but  not  of  the  arteries.  This  wandering  of  the 
white  corpuscles — diapedesis — is  accompanied  by  the  transudation 
of  blood  serum,  which  fills  the  surrounding  tissues,  causing  an 
edematous  swelling.  Later  on  the  red  blood  corpuscles  follow,  but 
they  migrate  in  very  much  smaller  quantities.  The  nature  of 
the  transudation,  the  quantity  of  the  blood  corpuscles,  and  the 
admixture  of  foreign  bodies  determine  the  character  of  the  in- 
filtration, as  it  may  be  a  serous,  fibrinous,  purulent,  hemorrhagic, 
or  croupous  exudate.  Another  important,  but  as  yet  less  recog- 
nized, symptom  of  inflammation  is  the  increased  osmotic  pressure 
within  the  infiltrated  area.  Hamburger^  and  others  have  shoAvn 
that  the  normal  osmotic  pressure  of  the  tissue  fluids  amounts  to 
about  7.5  to  7.9  atmospheres,  which,  when  exposed  relative  to 
the  freezing  point  of  a  physiologic  salt  solution,  equals  0.55°  to 
0.57°  C.  Under  normal  conditions  the  osmotic  pressure  is 
promptly  regulated  by  the  organism;  probably,  according  to  Mas- 
sart,  through  specific  nerves — that  is,  the  normal  equilibrium  of 
the  isotonic  index  of  the  blood  and  tissue  fluids  remains  station- 


^Manninger:   Heilung  Lokaler   Infectionen   mittelst   Hyperamie,    Wurzburger   Abhand- 
lungen,  Vol.  VI,  No.  6. 


ARTIFICIAL   HYPEREMIA 


445 


ary.  In  pathologically  altered  tissues  the  composition  is  contin- 
ually interfered  with,  and  usually  results  in  a  marked  increase  of 
the  osmotic  pressure— hypvirisotonicity.  Increased  osmotic  pres- 
sure produces  pronounced  morphologic  changes  in  the  cells,  and 
is  largely  responsible  for  the  resultant  pain,  followed  by  inflam- 
mation, within  the  affected  area.  According  to  Ritter^  the  A^a- 
rious  changes  in  tissues,  if  a  simple  abscess  is  taken  as  an  ex- 
ample, may  be  described  as  follows:  In  the  center  of  the  pus 
cavity  the  osmotic  pressure  may  reach  a  density  of  0.6°  to  1.4°  C. 
(0.56°  being  normal),  but  in  the  surrounding  hyperemic  zone 
the  pressure  is  less,  gradually  diminishing  in  the  manifest  edema, 
and  becoming  less  and  less  toward  the  periphery  until  normal 
pressure  is  reached.  Aside  from  these  quantitative  changes  with- 
in the  inflamed  area,  qualitative  changes  of  the  constituents  of 


Fig.  83. 

Schematic  drawing  of  an  abscess.  The  abscess  and  the  surrounding  infiltrated  area 
show  the  various  degrees  of  osmotic  pressure,  o,  abscess;  b,  hyperemic  zone;  c,  manifest 
edema;    d,    latent   edema. 


the  exudates  undoubtedly  have  some  important  significance.  The 
nature  of  these  latter  changes  is  at  present  too  obscure  to  allow 
any  definite  statements  to  be  made. 

Whenever  living  tissue  is  injured — whether  by  mechanical, 
thermal,  or  chemic  means — the  system  at  once  tries  to  protect 
itself  against  the  invading  foe  by  an  increased  rush  of  blood  into 
the  injured  area,  resulting  either  in  a  victorious  fight — complete 
resolution,  or  in  a  surrender  to  the  enemy — necrosis. 

Local  hyperemia,  which  is  the  forerunner  of  acute  inflamma- 
tion, results  from  an  increase  in  the  quantity  of  blood  in  the  in- 
jured part.  If  it  is  due  to  an  increase  in  the  flow  of  blood,  it 
is  referred  to  as  arterial  or  active  hyperemia,  while,  if  resulting 


*Schade:  Munchner  Medizinische   Wochenschrift,   1907. 


446  PHYSICAL   THERAPEUTICS 

from  an  obstruction  Avhich  retards  its  outflow,  it  is  known  as 
venous  or  passive  hyperemia.  In  active  hyperemia  the  involved 
area  is  bright  red  in  color,  and  the  temperature  is  slightly 
elevated  and  usually  accompanied  by  a  marked  swelling.  Passive 
hyperemia  manifests  itself  by  a  bluish-red  color  (cyanosis)  of  the 
involved  area,  with  a  somewhat  lessened  temperature.  The  veins 
are  distended,  and  an  edematous  swelling  is  soon  observed,  result- 
ing from  the  transudation  of  the  various  constituents  of  the 
blood.  The  cardinal  factors  of  the  early  stages  of  inflamma- 
tion which  bear  a  direct  relationship  to  the  proper  conception  of 
Bier's  hyperemic  treatment  are  the  migration  of  leucocytes,  the 
transudation  of  serum,  and  the  increased  activity  of  the  fixed 
tissue  cells.  At  present  it  seems  to  be  proved  that  the  therapeutic 
benefits  derived  from  hyperemia  find  an  explanation  in  the  bac- 
tericidal action  of  the  blood  serum.  To  enter  into  a  detailed"  dis- 
cussion of  the  nature  of  these  protective  substances — whether  they 
be  called  alexins,  antibodies,  lysins,  opsonins,  or  phagocytes — is 
of  no  consequence  in  our  present  consideration  of  the  subject. 
Let  it  suffice  to  say  that  nature  utilizes,  so  far  as  we  know,  three 
important  principles  of  self-protection  against  local  infection — 
preparation  of  the  way  for  transudation  of  the  serum,  positive 
chemotaxis,  and  increased  activity  of  cell  proliferation.  Quite  a 
number  of  theories  have  been  promulgated  to  explain  the  nature 
of  the  defensive  properties  of  hyperemia.  Buchner  claims  that 
the  increase  of  the  leucocytes  and,  in  consequence,  the  alexins  are 
the  factors.  Hamburger  believes  that  the  increased  amount  of  car- 
bonic acid  in  the  blood  as  a  sequence  of  the  congestive  hyperemia 
is  responsible.  The  same  views  are  shared  by  Chantemesse^  and 
Lubarsch.2  Notzel  favors  this  view,  provided  it  is  restricted  to 
recent  exudations,  while  Metchnikoff,  supported  by  Leyden, 
Lazarus,  and  others,  believes  that  the  phagocytotic  action  of  the 
leucocytes  is  the  predominating  factor.  Be  that  as  it  may,  the 
facts  remain  that  hyperemia  is  the  essential  factor  which  nature 
provides  in  a  more  or  less  pronounced  degree  to  combat  local  in- 
fection, and  that  we  owe  it  to  Bier  to  have  therapeutically  utilized 
this  very  same  principle,  artificially  provided,  to  assist  nature  in 
warding  off  disease  by  producing  inflammation.     It  seems  para- 


•  Chantemesse:  Academic  de  Medicine,   1903. 
'  Lubarsch:  AUgemeine  Pathologic,  1905. 


ARTIFICIAL    HYPEREMIA  447 

doxical  to  speak  of  warding  off  disease  by  providing  inflamma- 
tion. From  a  therapeutic  point  of  view,  it  has  been  our  aim  to 
treat  inflammation  by  antiphlogistic  measures,  while  the  Bier 
treatment  apparently  advocates  the  opposite — irritants.  An  ulti- 
mate analysis  of  the  action  of  antiphlogistics  will  convince  us, 
however,  that  in  reality  they  act  as  irritants  by  increasing  the 
factors  which  are  productive  of  inflammation  instead  of  diminish- 
ing them.  Bier  has  rightly  said  that  the  laity  is  not  so  foolish 
as  to  always  use  for  centuries  and  centuries  the  same  remedies  if 
they  were  of  no  value,  or  even  dangerous.  The  layman  ripens 
the  abscess  with  a  bread  and  milk  poultice,  or  some  similar  irri- 
tant. From  the  earliest  times  heat,  in  the  form  of  a  poultice 
or  fomentation,  has  been  applied  by  means  of  heated  rags,  stones, 
china,  etc.,  and  has  always  ruled  supreme  in  the  treatment  of  local 
infections.  Tincture  of  iodin  paint,  the  hot-water  bottle  or  the 
ice  bag,  the  modern  alcohol  poultice  or  the  Priessnitz  bandage, 
the  therapeutic  lamp  or  the  electric  light  bath,  and  massage  ac- 
complish in  reality  one  and  the  same  purpose — they  produce  cer- 
tain forms  of  artificial  hyperemia.  Many  of  these  remedies  act 
only  by  counterirritation,  producing  a  secondary  inflammation  in 
order  to  relieve  the  primary  irritation.  Bier  has  selected  two 
types  of  direct  mechanical  excitants  to  produce  two  definite  forms 
of  hyperemia — the  elastic  bandage  or  the  suction  cup  for  the  pro- 
duction of  passive  or  venous  hyperemia,  and  hot  air  for  the  pur- 
pose of  rushing  an  accelerated  blood  stream  into  the  tissues  by 
active  or  arterial  hyperemia.  Occasionally  these  two  forms  of 
artificially  produced  hyperemia  are  so  closely  blended  as  to  make 
it  impossible  to  draw  a  definite  line  of  demarcation.  Both  means 
are  very  powerful  therapeutic  agents,  and  consequently  their  cor- 
rect application  as  to  degree  and  duration  requires  a  delicate 
technique  in  order  to  produce  beneficial  results  only  and  not  do 
harm. 

The  advantages  of  hyperemic  treatment  over  other  therapeutic 
procedures  are  manifold.  Some  of  these  advantages  are  suppres- 
sion of  infection  and  avoidance  of  suppuration,  diminution  of 
pain,  and  culmination  of  pathologic  processes ;  large  incisions  into 
abscessed  cavities  may  be  entirely  dispensed  with;  simple  punc- 
tures, which  naturally  heal  quicker,  leaving  very  small  or  no 
scars,  are  usually  sufficient  for  drainage  by  the  suction  cup.  In 
the  very  early  stages  an  artificially  increased  inflammation  may 


448  PHYSICAL   THERAPEUTICS 

successfully  abort  an  incipient  infection,  and  in  already  existing 
suppuration  the  processes  of  demarcation  and  final  resolution  are 
materially  hastened. 

The  bactericidal  function  of  congestive  hyperemia  has  been 
fairly  well  established  by  carefully  conducted  experiments.  Notzel 
has  shown  that  an  injection  of  virulent  cultures  of  streptococci 
into  the  extremities  of  animals  subjected  to  a  powerful  con- 
gestive hyperemia  would  do  little  harm,  while  the  same  injection 
into  control  animals  invariably  produced  death.  It  is  furthermore 
sufficiently  proven  by  experimental  work,  as  well  as  by  clinical 
experience,  that  active  hyperemia  as  produced  by  direct  heat  ma- 
terially increases  the  absorption  of  watery  and  water-soluble  ma- 
terials by  the  capillaries,  and  not  by  the  lymph  vessels,  as  was 
formerly  believed,  all  solid  and  non-water-soluble  liquids  being 
absorbed  solely  by  the  lymphatics.^  These  two  factors  deserve 
to  be  seriously  considered  by  the  dental  surgeon  who  uses  such 
poisons  as  cocain,  epinephrin,  etc.,  for  injecting  into  the  gum  tis- 
sue. Absorption  is  lessened  during  hyperemia,  and  it  is  increased 
after  the  obstruction  is  removed. 

Local  hyperemia  exerts  a  definite  solvent  or  softening  power 
upon  exudates  which  may  have  collected  about  joints  or  in  the 
tissues — as  blood  clots,  joint  stiffness,  phlegmonous  infiltration, 
etc.  It  favorably  influences  nutrition,  and  it  seems  to  be  a  well- 
established  fact  that  the  formation  of  callus,  especially  the  amount 
of  calcium  salts,  in  the  repair  of  broken  bone  is  materially  in- 
creased. 

Methods  of  Inducing-  Hyperemia. 

The  Elastic  Bandage. — The  oldest  and  most  favored  method 
of  inducing  obstructive  hyperemia  is  tho  elastic  bandage.  The 
bandage  is  usually  made  of  soft  rubber,  but  for  dental  purposes  a 
bandage  made  of  garter  elastic  is  preferable.  The  material 
should  be  about  three-fourths  to  one  inch  wide  and  about  eighteen 
or  more  inches  in  length,  with  a  hook  at  one  end  and  a  number 
of  eyes  on  the  other.  In  general  surgery  the  bandage  is  usually 
applied  upon  the  extremities,  and  in  dental  surgery  it  is  used 
around  the  neck  for  the  purpose  of  producing  obstructive  hy- 
peremia of  the  head,  the  superficial  veins  being  very  amenable 


'  Mislowitzer:  Berliner  Zahnarztliche  Halbmonatsschrift,  1908,  p.  194. 


ARTIFICIAL    HYPEREMIA  449 

to  this  procedure.  A  few  simple,  but  important,  rules  govern  the 
successful  technique  of  the  application.  One  must  at  all  times  feel 
the  pulse  below  the  place  surrounded  by  the  bandage,  and  the 
technique  is  correct  if  there  is  absolutely  no  increase  of  pain,  and 
if  there  is  visible  hyperemia  of  the  part  subjected  to  this  treatment. 
Beginners  are  very  apt  to  place  the  bandage  too  tightly.  The 
bandage  must  partially  obstruct  only  the  superficial  veins,  and 
there  must  never  be  an  increase  of  pain.  The  bandage  is  placed 
about  the  neck  below  the  larynx.  It  should  feel  somewhat  like  a 
tight-fitting  collar,  but  it  must  never  produce  any  degree  of  dis- 
comfort, and  the  patient  is  the  best  judge  of  the  proper  fit.  Its 
action  may  be  increased  by  placing  upon  the  jugular  vein  a 
pledget  of  soft  cloth.  If  the  bandage  should  irritate,  a  strip  of 
flannel  may  be  placed  under  it.  Patients  suffering  from  arterio- 
sclerosis require  special  care.  When  treating  acute  inflammatory 
conditions  about  the  head,  a  slight  edema  may  be  easily  and  safe- 
ly produced.  Under  no  conditions  must  the  obstruction  be  so 
great  as  to  quickly  produce  a  dark,  bluish-red  color  or  red 
blotches.  The  tissues  located  distally  of  the  bandage  must  have 
a  slight  bluish-red,  but  never  a  white,  appearance.  Soon  after  the 
bandage  is  adjusted  the  focus  of  acute  inflammation  will  show  an 
increase  in  the  cardinal  symptoms — marked  redness,  heat,  and 
swelling,  but  with  a  slow,  definite  diminution  of  pain.  The  latter 
decreases  with  the  increase  of  the  edema.  It  should  be  remem- 
bered, however,  that  obstructive  hyperemia  does  not  and  will  not 
abort  an  abscess.  If  pus  is  present,  the  old  Hippocratian  postulate, 
ubi  pus  ibi  evacuatio  (where  pus  is  it  must  be  evacuated),  should 
be  rigidly  complied  with,  even  if  Bier's  treatment  is  to  be  used 
to  advantage,  or,  as  Meyer-Sehmieden  rightly  state,  "the  knife 
takes  care  of  the  pus — hyperemic  treatment  fights  the  inflamma- 
tion. ' '  The  bandage  placed  about  the  neck  for  the  purpose  of  com- 
bating acute  inflammation  should  remain  in  position  from  twenty 
to  twenty-two  hours  per  day,  when  it  should  be  removed  to  al- 
low the  slight  edemic  condition  to  pass  away.  Chronic  affections 
require  shorter  applications,  about  two  to  four  hours  per  day  hav- 
ing been  found  sufficient.  The  correctly  adjusted  bandage  can  be 
worn  with  perfect  comfort  and  safety  during  sleep. 

The  Suction  Cup. — The  suction  cups  used  for  the  purpose  of 
producing  congestive  hyperemia  are  made  of  glass,  ropresonting 
various   modifications   of   the   old-fashioned    cupping  glass.      De- 


450 


PHYSICAL   THERAPEUTICS 


pending  upon  the  various  surfaces  of  the  body,  bell-shaped  cups 
of  many  sizes,  or  tubes,  or  boot-shaped  vessels  provided  with  a 
nozzle,  are  emploj^ed,  and  maj^  be  procured  from  surgical  depots. 
Hyperemic  treatment  in  the  sense  of  Bier,  as  applied  to  dentistry, 


Fig.  84. 
Suction  cup  for  alveolar  abscesses  about  the  gums. 

is  as  yet  practiced  to  a  very  limited  extent  if  we  are  permitted  to 
judge  from  the  scarcity  of  the  literature  on  this  subject,  and  con- 
sequently the  special  apparatus  needed  for  dental  work  have  to 
be,  to  a  large  extent,  home-made.  The  larger  cups  intended  for 
work  on  the  external  surfaces  of  the  jaws  may  be  procured  from 


Fig.  85. 

Suction   cups   for   abscesses   about   the   cheeks,    lips,   and    chin. 

the  depots,  while  the  small  tubes  intended  for  the  oral  cavity  are 
readily  made  from  glass  tubing  by  bending  and  shaping  it  to 
the  proper  angles  over  a  Bunsen  flame.  The  end  of  a  soft  glass 
tube  of  suitable  size  is  held  in  the  hottest  part  of  the  flame  with 
the  left  hand,  and  continuously  rotated  to  insure  uniform  heat- 


ARTIFICIAL   hyperemia"  451 

ing,  until  it  becomes  soft.  A  heated  excavator  shank  is  now  held 
against  this  edge  at  the  proper  angle,  and  thus  the  lip  of  the 
tube  may  be  enlarged  and  its  edge  turned  over.  By  heating  the 
tube  beyond  the  cup-shaped  enlargement,  the  correct  bend  of 
the  tube  may  be  easily  obtained. 

Suction  is  accomplished  with  strong  rubber  bulbs,  or  with  the 
suction  pump  fastened  to  the  nozzle  of  the  cup  with  stout  rubber 
tubing.  The  action  of  the  suction  pump  is  best  illustrated  by 
the  working  of  a  bicycle  pump,  remembering,  of  course,  that  the 
reverse  action  of  the  pump  is  needed  for  suction.  The  author 
has  found  that  the  very  best  and  simplest  method  of  suction  is 
readily  obtained  by  utilizing  the  sucking  action  of  the  saliva  ejec- 
tor of  the  fountain  cuspidor.  By  means  of  a  short  piece  of  stout 
rubber  tubing  the  suction  cup  is  connected  with  a  piece  of  glass 
tubing  fastened  to  the  joint  of  the  saliva  ejector,  and,  by  regulat- 
ing the  water  pressure,  suction  of  the  desired  degree  is  readily 
obtained,  which  is  far  superior  to  any  other  means  of  suction.  All 
degrees  of  congestive  hyperemia  may  thus  be  obtained  with  per- 
fect precision  and  greatest  ease. 

Therapeutic  Indications. 

The  practice  of  dentistry  offers  a  wide  and  prolific  field  for 
the  application  of  Bier's  hyperemic  treatment.  The  indications 
for  its  use  are  manifold,  its  technique  is  extremely  simple,  and  the 
results  obtained  with  it  are  so  very  gratifying  that  it  deserves  the 
highest  recommendation. 

Congestive  Hyperemia  With  Elastic  Bandages. — Congestive 
hyperemia  by  means  of  the  elastic  bandage  is  primarily  indicated 
in  all  painful  disturbances  of  the  periosteum  of  the  teeth  and 
jaws.  It  is  a  well-known  fact  that  as  soon  as  the  cheek  swells— 
as  soon  as  nature  establishes  congestive  hyperemia  in  the  involved 
area— the  pain  arising  from  an  acute  pericementitis  will  cease. 
The  painful  periosteal  disturbances  arising  from  the  difficult 
eruption  of  a  third  lower  molar,  including  the  dangerous  phleg- 
monous infiltrations  about  the  angle  of  the  jaw  and  the  glandular 
enlargement  as  a  sequence  of  these  traumatic  or  infectious  in- 
juries, as  well  as  the  many  other  forms  of  pericementitis,  are 
especially  amenable  to  this  treatment.  Pain  following  inflamma- 
tion or  suppuration  after  the  offending  tooth  has  been  extracted 


452 


PHYSICAL   THERAPEUTICS 


is  much  benefited  by  the  application  of  the  bandage.  In  the 
various  forms  of  fractures  of  the  jaws  the  bandage  materially 
mitigates  the  resultant  pain  and  apparently  exercises  a  beneficial 
influence  on  callus  formation.  Facial  neuralgia  is  not  influenced 
by  congestive  hyperemia. 

The  technique  of  applying  the  bandage  has  been  alluded  to  on 
page  449.    The  bandage  should  be  continuously  applied  for  about 


Fig.  86. 

Application  of  the  elastic  bandage  for  the  production  of  obstructive  hyperemia  of  the 
head.  The  hyperemia  is  increased  by  placing  a  piece  of  soft  cloth  over  the  large  veins 
of  the  neck  beneath  the  bandage. 


twenty  hours,  or  twice  each  day  for  about  ten  hours  each  time, 
with  an  interval  of  two  hours.  It  should  be  borne  in  mind  that 
the  bandage  should  be  applied  with  just  a  sufficient  degree  of 
tightness  not  to  increase  the  pain.  It  must  never  strangulate, 
but  should  produce  a  visible  hyperemia  in  the  parts  under  treat- 
ment. 


ARTIFICIAL   HYPEREMIA 


453 


Treatment  of  Dental  Lesions  with  the  Suction  Cup. 


According  to  the  location  of  the  lesion  within  the  mouth,  the 
proper  suction  cup  or  tube  which  sufficiently  covers  the  inflamed 
area  is  selected,  and  a  thin  coat  of  vaselin  is  spread  over  its  rim 
to  insure  better  adhesion.  The  various  forms  of  suction  cups 
have  been  referred  to  on  page  450.  Klapp,  Bier's  former  assist- 
ant, and  WitzeP  and  his  assistant  Hauptmeyer  have  devised  cer- 


Fig.  87. 
Application  of  a  suction  cup  over  the  sinus  of  an  alveolar  abscess. 


tain  modifications  of  the  cups  so  as  to  make  them  amenable  to 
dental  purposes.  A  useful  small  cup,  especially  serviceable  for 
alveolar  abscess  treatment,  is  readily  made  by  slipping  a  soft 
rubber  polishing  cup  over  the  slightly  enlarged  end  of  an  eye 
pipette.  Hunter  has  advised  a  similar  treatment,  and  speaks  of 
it  as  follows :     One  of  the  rubber  cups  used  for  cleaning  teeth 


1  Witzel,  J.:     Die  Bierische  Stauung  und  dercn  Anwendung  als  Heilmittel  in  der  Zahn- 
heilkunde,  1906. 


454 


PHYSICAL   THERAPEUTICS 


and  mounted  on  a  mandrel  is  forced  down  flat  against  the  gum, 
covering  the  fistula,  and  by  removing  the  pressure  from  the  cup, 
but  keeping  its  edges  in  close  contact  with  the  gum,  a  suction  is 
created,  drawing  the  medicament  through  the  abscess  tract.  If 
syphon  suction  is  not  available,  a  stout  rubber  bulb  slipped  over 
the  end  of  the  cup  or  tube  answers  the  purpose.  If  the  cup  is 
used  in  connection  with  the  syphon  of  the  fountain  cuspidor,  a 
U-shaped  piece  of  glass  tubing  is  inserted  between  the  syphon  and 
the  cup  proper  to  act  as  a  receptacle  for  pus  and  blood.  The 
suction  must  be  of  a  mild  degree,  and  is  applied  but  once  a  day 


Fig.  88. 

Hyperemic  suction  cup  applied  to  a  chin  fistula.     This  fistulous  opening  was  caused  by  a 
dead  pulp  in  a  lower  incisor. 


for  about  three-quarters  of  an  hour — five  minutes  at  a  time,  with 
three  minutes'  intermission,  repeating  the  suction  five  to  six  times 
at  the  same  sitting.  If  this  treatment  is  applied  in  the  early 
stages  of  pericemental  trouble,  the  formation  of  an  abscess  may  be 


ARTIFICIAL    HYPEREMIA 


455 


readily  aborted,  provided  the  root  canal  of  the  affected  tooth  has 
been  properly  cleansed  and  drained,  and  suitable  antiseptics  have 
been  applied.  If  suppuration  has  already  set  in,  the  abscess  is 
simply  punctured,  and  no  large  incision  is  necessary.  The  cup 
is  now  applied  for  further  treatment,  which  must  be  continued 
until  all  infiltration  has  subsided.     After  the  second  treatment, 


Fig.  89. 

Suction  cup  applied  to  a  fistula  on  the  cheek  near  the  border  of  the  mandible.  The 
abscess  is  caused  by  a  dead  pulp  in  a  lower  molar.  The  cup  is  connected  with  the  syphon 
of  the  fountain  cuspidor. 

usually  nothing  but  blood  is  drawn  away  by  the  cup,  and,  if  some 
strong  antiseptic — as  a  solution  of  iodin  in  cresol — is  placed  into 
the  root  canal,  it  is  readily  sucked  through  the  fistula. 

If  an  alveolar  abscess  opens  on  the  face,  the  treatment  by  the 


456  PHYSICAL   THERAPEUTICS 

suction  cup  is  practically  the  same,  only  that  suitabla  larger  cups 
have  to  be  used.  If  a  crust  has  formed  over  the  fistula,  it  must 
be  removed  before  suction  is  started.  A  simple  ointment  dress- 
ing held  in  place  by  collodion  is  applied  after  the  treatment.  Ab- 
scesses treated  in  this  manner  practically  leave  no  disfiguration 
on  the  face  after  cicatrization  has  set  in. 

In  the  treatment  of  an  acute  abscess  without  a  fistula  (blind 
abscess),  suction  also  is  employed  with  marked  benefit.  The  root 
canal  must  be  thoroughly  cleansed,  and  the  foramen  is  slightly 
enlarged  before  suction  is  started.  Two  methods  of  applying  the 
suction  cup  are  in  vogue — a  large  hypodermic  needle  is  cemented 
into  the  root  canal  Avith  temporary  stopping,  or  a  short  thick- 
walled  rubber  tube  is  drawn  over  the  tooth.  Either  appliance  is 
now  connected  by  means  of  glass  and  rubber  tubes  with  the  rub- 
ber bulb  or  the  syphon.  DilP  and  Schroder^  have  advised  the  use 
of  a  powerful  metal  syringe  (aspirator)  for  this  treatment,  while 
Miller'  praises  the  syphon  of  the  fountain  cuspidor  as  a  good  suc- 
tion medium. 

Congestive  hyperemia  applied  in  the  treatment  of  certain 
stages  of  pyorrhea  alveolaris  is  of  marked  benefit.  Specific  ap- 
paratus are  needed  for  each  case,  but,  as  they  are  difficult  to 
adjust,  their  general  application  is  limited.  Schroder^  has  pub- 
lished some  preliminary  reports  concerning  this  method  of  treat- 
ment, but  the  apparatus  used  by  him  was  rather  cumbersome. 
A  special  suction  cup  has  to  be  constructed  for  each  individual 
case.  A  cup  for  the  anterior  lower  teeth  may  be  made  of  hard 
vulcanite,  with  a  rim  of  soft  velum  rubber,  from  a  model  of  the 
involved  parts,  or  a  cup  may  be  made  from  an  impression  taken 
in  modeling  compound.  Suitable  traj^s  for  such  work  are  con- 
structed and  used  as  foUoAvs:  The  handle  and  heels  of  a  lower 
Angle  impression  tray  are  cut  off ;  a  hole  a  quarter  of  an  inch  wide 
is  drilled  in  the  center  of  the  tray,  and  a  piece  of  brass  tubing 
three-eighths  of  an  inch  long  is  soldered  into  the  hole;  the  cup 
is  now  trimmed  so  as  to  fit  the  involved  area  as  nearly  as  pos- 
sible; the  tray  is  filled  with  modeling  compound  and  an  impres- 


*Dill:  Schweizer  Vierteljahrsschrift  fiir  Zahnheilkunde,  1901,  No.   3. 

*  Schroder:  Deutsche  Monatsschrift  fiir  Zahnheilkunde,  1907,  p.  356. 
'  Miller:  Lehrbuch  der  Konservativen  Zahnheilkunde,  1908. 

*  Schroder:   Loc.  cit. 


ARTIFICIAL   HYPEREMIA 


457 


sion  is  taken  of  the  involved  lower  anterior  teeth,  pressing  the 
tray  as  deeply  as  possible  into  position;  six  or  even  eight  teeth 
may  be  covered  by  the  tray.  The  tray  is  now  removed,  and  the 
modeling  compound  is  cut  away  from  the  inner  surface  of  the 
cup,  leaving  only  a  thick  continuous  roll  of  compound  covering 
the  rim  of  the  tray;  the  tray  is  now  connected  with  the  syphon, 


Fig.  90. 

Hyperemic  suction  apparatus  for  the  treatment  of  pyorrhea  alveolaris.  A  specially  pre- 
pared impression  cup  for  the  lower  incisors,  lined  with  a  rim  of  softened  impression 
compound  and  connected  by  a  piece  of  rubber  tubing  with  a  suction  pump. 


or  a  strong  syringe,  or  a  pump,  and  the  compound  rim  is  slightly 
warmed  and  placed  over  the  soft  tissue,  the  latter  being  thoroughly 
dried  and  covered  with  a  thick  film  of  vaselin  to  facilitate  the 
formation  of  an  air-tight  joint.  A  cup  for  the  molars  and  bi- 
cuspids may  be  constructed  on  similar  principles  from  the  cut- 


458  PHYSICAL   THERAPEUTICS 

off  heels,  and  other  suitable  modifications  which  may  be  needed 
are  left  to  the  ingenuity  of  the  operator.  The  suction  must  be  of 
a  mild  degree,  and  is  applied  but  once  a  day  in  short  repetitions, 
as  outlined  above. 

In  acute  forms  of  empyema  of  the  maxillary  sinus,  congestive 
hyperemia  produced  by  suction  or  by  the  elastic  bandage  deserves 
to  be  recommended.  In  chronic  cases  it  is  of  no  benefit  what- 
soever. 

Active  Hyperemia. 

Pronounced  active  hyperemia  is  readily  produced  by  dry  hot 
air  or  by  moist  heat.  The  sources  of  heat  may  be  manifold.  Dry 
heat  is  readily  obtained  from  a  gas  flame,  coal  oil  lamp,  electric 
heater  or  light  globe,  Japanese  pocket  stove,  hot-water  bag,  etc., 
and  moist  heat  from  a  hot  wet  pack  or  a  poultice.  Bier  advises  the 
use  of  hot  air  conveyed  through  a  tube  provided  with  a  nozzle, 
which  sprays,  as  it  were,  the  heated  air  over  the  affected  parts. 
He  also  advocates  the  use  of  hot-air  boxes — boxes  so  shaped  as 
to  accommodate  the  diseased  part  of  the  body,  to  which  the  hot  air 
is  conveyed.     The  latter  are  rarely  applicable  to  dental  lesions. 

Therapeutic  Applications. 

Acute  and  particularly  chronic  inflammation  and  their  sequelse 
— adhesions,  infiltrations,  and  exudations — are  readily  amenable 
to  active  hyperemic  treatment.  Of  the  specific  diseases,  neuralgia 
in  its  various  forms  is  especially  favorably  influenced  by  heated 
air.  The  affected  part  is  brushed  over  with  the  hot  douche  or 
with  the  therapeutic  lamp  for  about  ten  minutes,  and  imme- 
diately after,  or  even  during,  the  heat  application  is  kneaded 
and  rubbed  by  massage  movements.  If  the  therapeutic  lamp  (see 
page  465)  is  used  in  this  connection,  no  asbestos  screen  is  neces- 
sary for  the  protection  of  the  parts. 

MASSAGE. 

Massage  (kneading  or  rubbing)  is  a  therapeutic  measure  em- 
ployed for  the  purpose  of  treating  diseases  by  mechanical  move- 
ments. In  medicine  it  is  known  by  various  terms — kinesitherapy 
(motion  treatment),  mechanotherapy,  massotherapy,  and,  recent- 
ly, osteopathy.    Massage  is  one  of  the  most  ancient  remedial  agents, 


MASSAGE  459 

and  in  the  form  of  medical  gymnastics  it  has  played  an  important 
part  in  the  destiny  of  many  nations.  Its  systematic  employment 
has  been  equally  lauded  in  bygone  days  by  the  physicians  of  Baby- 
lon, Alexandria,  Athens,  and  Rome,  and,  while  Europe  of  today 
enjoys  a  revival  of  massage  under  the  name  of  Swedish  move- 
ment, the  United  States,  the  "land  of  unlimited  possibilities," 
has  its  modern  apostle  of  the  art  of  kneading  in  the  person  of 
Dr.  Still,  the  founder  of  the  osteopathic  cult.  Hippocrates,  in 
his  medical  aphorisms,  advises  that  "the  physician  ought  to  be 
acquainted  with  many  things,  and,  among  others,  with  friction." 
The  therapeutic  results  of  massage  seemed  to  be  fully  appreciated 
by  him,  for  he  declares  that  "rubbing  can  bind  a  joint  that  is 
too  loose,  and  can  loosen  a  joint  that  is  too  rigid;  that  much 
rubbing  causes  parts  to  waste,  while  moderate  rubbing  makes 
them  grow."  The  Chinese  and  Japanese  are  thoroughly  familiar 
with  muscle  kneading,  and  the  marvelous  dexterity  of  the  am- 
ma,  the  blind  Japanese  masseur,  excites  the  surprise  and  admira- 
tion of  the  western  visitor.  Even  the  aboriginal  inhabitants  of 
Africa  and  the  South  Sea  islands  practice  massage  in  one  form  or 
another,  and  it  is  quite  fashionable  in  Honolulu  to  be  "lomi- 
lomied"  after  a  hearty  meal.  The  lomi-lomi  is  used  not  only  by 
the  natives,  but  among  almost  all  the  foreign  residents;  and  not 
merely  to  procure  relief  from  weariness  consequent  to  overexer- 
tion, but  to  cure  headaches,  to  relieve  the  aching,  and  neuralgic, 
and  rheumatic  pains,  and  by  the  luxurious  as  one  of  the  pleasures 
of  life. 

In  1780  Tissot  reintroduced  massage  into  France,  and  his  and 
Meibom's  (1795)  writings  helped  much  to  popularize  it  among 
the  masses.  It  was  revived  by  Metzgcr,  of  Amsterdam,  and  his 
pupils  in  1873.  Henry  Peter  Ling,  of  Stockholm,  worked  out  a 
system  of  mechanotherapeutics,  which  has  become  famous  as 
the  Swedish  movement,  or  Lingism,  and  especially  through  Schrci- 
ber's  manual  on  "Massage  or  Methodical  Muscle  Exercise"  it  has 
gained  access  to  medical  clinics  of  both  continents. 

By  massage  we  understand  a  series  of  mechanical  movements 
best  executed  by  the  hands  of  the  operator,  affecting  the  skin  as 
well  as  the  deeper  structures  of  the  body.  To  employ  it  on  a 
scientific  basis,  a  fair  knowledge  of  regional  anatomy  and  physi- 
ology must  necessarily  be  possessed  by  the  operator.  It  is  some- 
what difficult  to  describe   minutely  the  various  movements   em- 


460  PHYSICAL   THERAPEUTICS 

ployed  in  the  art  of  massaging,  and  they  are  best  acquired  by 
personal  instructions  bj^  a  skilled  operator.  The  object  of  massage 
is  to  bring  about  increased  cell  activity  in  the  parts.  Massage  in- 
creases the  flow  of  body  juices — blood,  lymph,  chyle,  etc. — in- 
creases secretion  and  excretion,  and  excites  muscular  activity.  In 
general,  its  physiologic  effects  and  therapeutic  advantages  are 
nearly  identical  with  those  obtained  from  any  other  source  which 
is  capable  of  producing  artificial  hyperemia. 

The  technique  of  massage  may  be  divided  into  the  following 
methods  of  application:  Stroking,  friction,  kneading,  percussion, 
and  vibration,  active  and  passive  movements,  or  medical  gym- 
nastics. The  movement  of  the  hands  in  applying  massage  de- 
pends on  the  method  employed.  In  stroking,  the  whole  palm  or 
the  radial  border  of  the  hand,  or  the  tips  of  the  fingers,  are  used, 
the  pressure  being  light  in  the  beginning  and  gradually  increas- 
ing to  as  much  force  as  the  case  demands.  The  direction  of  the 
strokes  in  most  cases  is  venous — centripetal,  or  toward  the  heart. 
Upon  the  head  the  movements  are  directed  from  the  vertex  down- 
ward. Friction  is  best  applied  by  forcible,  circular  rubbing  of 
the  surface,  starting  at  the  border  of  the  altered  tissues  and  work- 
ing toward  the  center  from  all  directions.  In  kneading,  squeez- 
ing, rolling,  etc.,  the  movements  of  pressure  and  relaxation  are 
alternately  and  rhythmically  employed  to  simulate  natural  mus- 
cular action,  the  object  being  to  act  upon  the  circulation  of  the 
deeper  seated  structures.  The  veins,  capillaries,  lymph  vessels, 
and  lymph  spaces  are  emptied  by  pressure,  the  valves  in  the  ves- 
sels preventing  a  return  of  the  expelled  fluids,  but  making  room 
for  a  fresh  influx.  Percussion  and  vibration  consist  of  a  series 
of  tapping,  pounding,  or  beating  movements  very  rapidly  and 
rhythmically  performed  with  the  fingers,  with  the  radial  border 
of  the  hands,  or  by  means  of  mechanical  contrivances  worked  by  the 
hand,  a  spring,  or  electricity,  which  causes  muscular  contraction. 
In  the  active,  or  Swedish,  movement  the  patient  concentrates  his 
will  on  the  muscle  under  treatment,  causing  it  to  act,  while  the 
operator  tries  to  resist  the  movement  with  slightly  less  force.  Af- 
ter the  muscle  has  fully  contracted,  the  operator  employs  force, 
while  the  patient  diminishes  his  resistance,  until  the  muscle  is 
brought  back  to  its  original  position.  In  passive  massage  all  the 
movements  of  the  muscles  and  joints  are  executed  by  the  operator 
without  resistance  or  assistance  on  the  part  of  the  patient. 


MASSAGE 


461 


Medical  gymnastics  ai'e  principally  employed  for  the  purpose 
of  exercising  all  those  muscles  which  are  seldom  used,  or  which, 
for  some  special  reason,  require  strengthening. 

From  the  viewpoint  of  the  dental  therapeutist,  mas- 
sage is  a  serviceable  adjunct  to  his  armamentarium. 
It  is  indicated  in  all  those  conditions  where  a  sluggish 
circulation  in  the  soft  tissues  exists,  and  consequently 
all  those  diseases  in  which  chronic  inflammation  is  an 
etiologic  factor — gingivitis,  pyorrhea  alveolaris,  etc. — 
are  directly  amenable  to  this  treatment.  As  a  prophy- 
lactic measure,  massage,  in  combination  with  the  dail}^ 
routine  toilet  of  the  mouth,  deserves  to  be  highly  rec- 
ommended. In  the  mouth  proper  the  finger  (bare  or 
covered  with  a  coarse  linen  finger  cot  or  stall),  the 
tooth  brush  (made  of  soft  or  coarse  bristles,  rubber, 
or  woody  fibers),  or  even  some  specially  devised  me- 
chanical appliances,  are  used.  Existing  conditions 
and  the  individuality  of  the  patient  govern  the  meth- 
ods and  their  application.  The  operator  has  to  decide 
which  grade  and  what  kind  of  a  tooth  brush  is  best 
for  the  ease  in  hand.  Rotary  movement  and  moderate 
pressure  applied  by  a  fairly  coarse  brush  apparently 
produce  better  results  than  a  too  soft  or  a  too  coarse 
brush  used  with  heavy  friction.  The  time  required 
for  oral  massage  is  also  dependent  on  conditions.  On 
the  average  about  five  minutes  three  times  daily  are 
sufficient.  For  external  facial  massage,  the  finger  tips 
or  the  electric  vibrator  are  indicated.  This  also  de- 
pends on  conditions,  the  operator  selecting  the  method 
best  suited  to  his  purpose.  An  electric  dental  vibrator 
has  been  devised  and  advocated  by  Mitchell.^  It  con- 
sists of  a  "cam-like  piece  of  metal,  perforated  at 
its  smaller  end  for  mounting  upon  a  screw  mandrel,  ^-^  g^ 
and  is  held  in  the  dental  hand  piece  strapped  to  the  j^^^^^,  ^ji^rator.' 
hand.  Its  centrifugal  force  imparts  a  vibratory  mo- 
tion to  the  hand,  which  can  be  utilized  for  massage  with  the 
finger  tips,  or  by  holding  in  the  hand  an  instrument  having  on 

»  Mitchell:  Dental  Brief,  1908. 

*  An  S.  S.  White  engine  mallet  is  provided  with  a  soft  or  hard  rubber  cup.  mounted 
on  a  suitable  shank.  Any  desired  degree  of  speed  and  force  is  readily  obtained  hy  the 
proper  regulation  of  the  mallet. 


4(i2 


PHYSICAL   THERAPEUTICS 


Fig.  92. 
Dental  massage  apparatus.     (Vibrator.) 


LIGHT   THERAPY  463 

its  end  a  soft  rubber  cup.  The  parts  to  be  massaged  should  be 
lubricated  with  vaselin,"  Ointments  are  used  merely  for  the 
purpose  of  rendering  the  skin  soft  and  pliable,  and  to  enable  the 
fingers  to  glide  easily  over  the  surface.  Mechanical  vibrators 
suitable  for  the  oral  cavity  are  at  present  to  be  found  in  the 
market.  An  instrument  for  the  purpose  may  be  readily  con- 
structed as  follows :  A  suitable  mandrel  is  provided  with  a  threaded 
shank  to  fit  the  socket  of  an  S.  S.  White  engine  mallet  No.  4. 
The  mandrel  is  bent  to  a  slight  obtuse  angle,  and  mounted  with 
a  soft  rubber  tip,  or  Morrison  polisher;  or  a  number  of  mounted 
cups  and  tips  are  kept  on  hand,  and,  when  needed,  securely 
fastened  in  a  suitable  porte  polisher.  Any  desired  degree  of 
speed  and  force  is  readily  obtained  by  the  proper  regulation  of  the 
mallet.  It  has  been  stated  that  a  moose  hide  disk,  mounted  off 
the  center  and  rotated  in  the  dental  engine,  produces  sufficient 
vibration  for  dental  purposes.  While  this  is  true,  the  rapid  rota- 
tion will  incidentally  produce  a  rubbing  motion,  which  readily 
lacerates  the  gum  tissue  by  brushing  away  its  epithelial  coating. 
The  electric  vibrator  employed  by  professional  masseurs  should 
be  used  with  caution  on  the  face,  as  the  author  has  seen  a  case 
where  the  too  powerful  strokes  of  the  instrument  on  the  cheek  of 
a  lady  almost  completely  knocked  out  a  single  standing  lower  molar. 

LIGHT  THERAPY. 

Within  recent  years,  light,  in  the  form  of  sunlight  or  artificial 
light,  has  been  freely  discussed  as  a  therapeutic  agent  of  some  im- 
portance. A  comprehensive  knowledge  of  light  rays  from  the 
physicist's  point  of  view  is  essential  to  a  clear  understanding  of 
their  therapeutic  action.  The  solar  spectrum  furnishes  a  band 
of  colors  consisting  of  violet,  indigo,  blue,  green,  yellow,  orange, 
and  red  shades,  which  overlap  each  other.  Beyond  either  end 
of  the  spectrum  there  are  found  a  number  of  rays,  the  more  im- 
portant ones  being  known  as  the  infra-red  and  the  ultra-violet 
rays.  Certain  rays  possess  specific  functions.  The  infra-red  rays 
are  heat  producers,  and  are  spoken  of  as  thermic  or  caloric  rays; 
the  yellow  and  green  rays  are  predominant  in  the  production  of 
light  and  are  referred  to  as  luminous  rays,  while  the  blue  and 
violet  rays,  especially  the  ultra-violet  rays,  exercise  a  marked 
chemic  influence  on  organic  and  inorganic  matter,  and  are  known 


464  PHYSICAL   THERAPEUTICS 

as  chemic  or  actinic  rays.  Concerning  the  therapeutic  value  of 
the  various  rays,  it  is  known  that  the  thermic  rays  produce  active 
hyperemia,  the  actinic  rays  exercise  a  definite  chemic  influence 
on  cell  structure,  and  the  luminous  rays  possess  an  analgesic 
effect.  By  special  constructed  apparatus  certain  rays  may  be 
concentrated,  others  may  be  eliminated,  and  combinations  of  the 
rays  in  varying  degrees  may  be  produced  at  will.  The  various 
sources  of  light  employed  for  therapeutic  purposes  are  direct  sun- 
light, the  Finsen  light,  and  the  incandescent  globe.  For  dental 
purposes,  direct  sunlight  is  probably  rarely  used.  The  Finsen 
light,  on  account  of  its  expense,  is  largely  confined  to  special 
sanatoria,  while  the  incandescent  globe,  on  account  of  its  sim- 
plicity, deserves  to  be  recommended. 


Fig.  93. 
Dental  electric  therapeutic  lamp. 

The  Finsen  lamp  produces  an  intense,  cold  light ;  it  is  especially 
rich  in  ultra-violet  rays,  while  the  thermic  rays  have  been  largely 
excluded.  The  chemic  influence  of  the  Finsen  light  manifests  it- 
self principally  in  the  destruction  of  the  pus-producing  elements, 
without,  however,  unfavorably  influencing  cell  proliferation.  Its 
essentially  preservative  action  results  in  the  formation  of  white, 
smooth  sears,  without  contraction  of  the  tissues.  The  Finsen 
light  is  much  lauded  for  the  treatment  of  lupus  and  similar  dis- 
eases of  the  skin  and  mucous  membranes.  As  stated  above,  the 
therapeutic  action  of  the  mixed  light  rays  is  destructive  to  micro- 
organisms; the  rays  act  as  analgesics,  and  they  produce  intense 
active  hyperemia,  with  all  its  sequences.  We  possess,  however,  at 
present  so  very  little  definite  knowledge  concerning  their  action 


LIGHT   THERAPY 


465 


on  living  tissue  that  positive  statements  regarding  their  therapeutic 
indications  should  be  regarded  only  as  possibilities  based  largely 
on  empiricism. 

The  electric  light  best  suited  for  dental  purposes  is  a  one-hun- 
dred-candle power  incandescent  globe,  having  a  hard  carbon  fila- 
ment, and  inclosed  in  a  suitable  projector.  Much  confusion  ex- 
ists regarding  the  relative  therapeutic  value  of  lamps  of  different 
candle  power.  It  should  be  borne  in  mind  that  a  one-hundred- 
candle  power  lamp  is  just  as  efficient,  therapeutically  speaking,  as 
a  five-hundred-candle  power  light.  The  patient  can  bear  only  a 
certain  amount  of  heat,  and  any  more  heat  produced  by  the 
lamp  is  wasted.     A  one-hundred-candle    power    lamp    furnishes 


Fig.  94. 
Dobrzyntecki's  heat  and  light  reflector,     o,  lens;  b,  lens;  c,  lens;  d,  flame;  *,  mirror. 


sufficient  caloric  rays  to  readily  burn  tissue.  The  projector  should 
be  of  the  parabolic  type — that  is,  so  constructed  as  to  furnish 
parallel  rays  only.  It  is  claimed  that  the  metal  best  suited  for  a 
reflector  is  an  alloy  of  aluminum  and  manganese.  To  modify 
or  intensify  the  various  rays  of  this  lamp,  yellow,  blue,  or  amber 
colored  glass  screens  may  be  clamped  to  the  projector.  A  free 
current  of  air  should  circulate  through  the  reflector,  as  this  will 
prevent  ready  blistering  of  the  patient.  In  using  a  high  power 
lamp,  a  quick-acting  switch  is  necessary,  as  all  other  forms  of  cut- 
offs readily  burn  out.  If  electricity  is  not  available,  a  common 
coal  oil  lamp,  with  a  one-half-inch  round  burner,  provided  with  a 
reflector,  answers  the  purpose  fairly  well.     A  simple  and  efficient 


466 


PHYSICAL   THERAPEUTICS 


reflector  may  be  constructed,  according  to  Dobrzyniecki,^  as  fol- 
lows: A  three-inch  convex  mirror  reflects  the  rays  through  a 
plano-concave  lens  two  inches  in  diameter;  the  longer  end  of  the 
cone-shaped  connecting  tube,  being  about  ten  inches  long,  is  pro- 
vided at  its  largest  diameter  with  a  three-inch  double  convex 
lens;  the  small  end  of  the  tube  measures  about  four  inches,  and 
has  a  two-inch  double  convex  lens  near  the  outlet.  The  rays  are 
reflected  by  the  mirror  and  pass  through  the  series  of  lenses,  the 
last  one  being  brought  in  close  contact  with  the  patient. 

Therapeutic  Applications. 

In  the  practice  of  dentistry  the  mixed  rays  of  light  obtained 
from  what  is  technically  known  as  a  one-hundred-eandle  power 


Fig.  95. 

Mode  of  application  of  the  therapeutic  lamp.  The  therapeutic  portable  lamp  is  g^uided 
by  the  operator.  The  patient  protects  himself  with  an  asbestos  screen,  which  has  a  hole 
out  near  the  center  to  allow  the  rays  to  pass   through. 

therapeutic  lamp  are  usually  employed.  In  the  mouth  proper 
only  the  anterior  teeth  and  gum  tissue  are  directly  amenable 
to  this  treatment.     To  expose  the  parts  as  much  as  possible,  a 


*  Dobrzyniecki :    Wiener  ZahnarztHche  Monatsschrift,   1903,   p.    287. 


LIGHT   THERAPY  467 

mouth  speculum  is  inserted,  and  the  patient's  face  is  protected  by 
an  asbestos  screen,  with  an  opening  cut  in  the  center  about  two 
inches  long  and  one-half  inch  wide,  which  is  held  by  the  patient 
about  two  inches  in  front  of  the  parts  to  be  treated.  The  lamp 
is  held  in  front  of  the  screen,  the  distance  depending  on  the  degree 
of  heat  produced.  The  light  is  used  with  a  brushing  motion,  and 
should  not  be  focused  too  persistently  on  any  one  point.  On  the 
face  it  is  used  in  practically  the  same  manner.  A  thin  coat  of 
vaselin  spread  over  the  surface  to  be  treated  relieves  undue  ten- 
sion. To  receive  the  full  benefit  of  the  light  treatment,  the  part 
to  be  treated  should  be  continuously  exposed  twice  at  one  sitting 
for  about  fifteen  minutes  each  time,  with  an  interval  of  half  an 
hour,  and  preferably  immediately  followed  by  massage. 

Radio-Active  Substances. 

In  1896  Roentgen  made  the  world-renowned  discovery  that  cer- 
tain rays  obtained  from  a  Crookes  tube  would  penetrate  sub- 
stances which,  under  ordinary  conditions,  are  known  to  be  opaque. 
In  the  same  year  the  late  French  physicist,  Henry  Becquerel, 
observed  that  uranium  salts,  when  brought  into  contact  with  a 
photographic  plate  protected  by  a  tight-fitting  cover  of  black 
paper,  become  sensitized.  Certain  substances  are  known  to  pos- 
sess the  power  of  emitting  light  rays,  i.e.,  they  cause  fluorescence 
or  phosphorescence.  It  should  be  borne  in  mind,  however,  that 
these  latter  substances  have  to  be  exposed  to  sunlight  or  artificial 
light  for  some  time  before  they  re-emit  some  of  this  stored-up 
energy  in  the  form  of  light  rays.  On  the  other  hand,  minerals 
which  contain  uranium  will  bring  about  the  same  phenomenon 
without  being  previously  exposed  to  light  rays. 

Light  is  a  form  of  energy;  it  cannot  be  completely  destroyed 
nor  can  it  be  created  out  of  nothing.  Since  uranium  salts  pro- 
duce light  rays  apparently  indefinitely,  it  was  supposed  that  they 
must  contain  certain  specific  substances  which  possess,  as  an  in- 
herent property,  the  power  of  light  emanation.  The  isolation 
of  these  substances  was  finally  accomplished,  and  their  discovery 
is  primarily  to  be  credited  to  the  late  Professor  Pierre  Curie  and 
to  his  wife,  Mme.  Curie,  of  Paris.  Both  experimenters  worked 
with  crude  uranium  minerals  and  from  it  they  isolated  radium — 
the  radiant — and  polonium,  so  termed  in  honor  of  Mme.  Curie's 


468  PHYSICAL   THERAPEUTICS 

native  country,  Poland.  Shortly  after  the  discovery  of  these  two 
elements,  Debierne  of  Paris  isolated  a  third  radio-active  element 
from  the  crude  uranium,  which  he  named  actinium. 

The  chief  minerals  from  which  radium  is  derived  are  carnotite 
or  ehalkolite,  and  pitchblende.  The  quantity  of  radium  present 
in  the  various  minerals  is  extremely  small,  about  five  million  parts 
of  pitch-blende  containing  one  part  of  radium.  A  ton  of  pitch- 
blende, containing  about  fifty  per  cent  of  uranium,  furnishes  about 
two  grains  (0.13  grams)  of  radium.  To  extract  this  small  quan- 
tity, tedious  mineralogic  processes  are  necessary.  The  present 
available  amount  of  radium  throughout  the  whole  globe,  expressed 
as  the  bromid  salt,  may  be  estimated  at  about  an  ounce  and  a  half 
(45  grams),  which  represents  a  value  of  about  five  million  dollars. 
One  milligram,  i.e.,  about  one-sixty-fourth  of  a  grain,  is  listed  at 
present  (1915)  at  one  hundred  and  twenty  dollars. 

Radio-Active  Substances. — These  substances  may  be  classified  in 
three  distinct  groups:  Actinium,  thorium,  and  uranium.  Each 
primary  element,  by  transmutation,  transforms  itself  into  a  num- 
ber of  other  substances.  According  to  Rutherford  and  Soddy,  all 
radio-active  substances  are  continuously  undergoing  transforma- 
tion. During  the  transformation  of  a  radio-active  element,  an- 
other element  is  created  whose  atoms  possess  less  power  of  emana- 
tion than  is  possessed  by  the  one  from  which  it  is  created.  Re- 
stricting our  discussion  to  uranium  and  thorium  only,  the  follow- 
ing substances  derived  from  the  respective  mother  substances  may 
be  enumerated:  Uranium,  Uranium  X,  Ionium,  Radium,  Radium 
emanation.  Radium  A,  Radium  B,  Radium  C,  Radium  D,  Radium 
E,  and  Radium  P.  Thorium,  during  the  process  of  transforma- 
tion, produces  the  following  so-far-known  substances:  Thorium, 
mesothorium,  radiothorium,  Thorium  X,  Thorium  emanation, 
Thorium,  A,  B,  C,  and  D.  Incidentally,  the  products  of  transforma- 
tion possesses  a  variable  period  of  "life,"  i.e.,  time  of  existence.  A 
specific  quantity  of  radium  decomposes  by  about  one-half  in  seven- 
teen hundred  years,  radium  emanation  in  3.8  days,  radium  A  in 
three  months,  radium  B  in  twenty-six  minutes,  radium  C  in  nine- 
teen minutes,  radium  D  in  twelve  years,  radium  E  in  six  days, 
and  radium  F  in  one  hundred  and  forty  days. 

Radium  is  an  element  closely  related  to  barium  in  its  chemical 
behavior.  It  is  a  white  metal,  melting  at  about  1,316°  F.  (700° 
C),  and  energeticallj^  decomposes  water.    Aside  from  the  ordinary 


LIGHT   THERAPY  469 

properties  possessed  by  the  barium  group,  it  is  endowed  with  three 
remarkable  additional  functions:  It  emits  heat  continuously  at  a 
constant  rate,  it  is  the  source  of  radiation,  and  it  generates  a  gas 
which  is  radio-active. 

Radiation  Energy. — The  transformation  of  one  radio-active  ele- 
ment into  another  is  a(Jcompanied  by  the  liberation  of  various  rays, 
which  are  known  as  the  alpha,  beta,  and  gamma  rays.  Alpha  and 
beta  rays  are  not  true  rays ;  the  alpha  rays  are  positively  charged 
ions  of  helium  given  off  by  the  element,  while  the  beta  rays  are 
negatively  charged  ions.  The  gamma  rays  are  true  rays;  they  do 
not  contain  free  ions  and  are  very  similar  to  the  Roentgen  rays. 
The  gamma  rays  are  not  distorted  in  a  magnetized  field,  while  the 
other  two  rays  are  turned  to  the  right  or  left  respectively.  The 
power  of  penetration  of  these  various  rays  differs  markedly;  the 
alpha  rays  are  least  active,  the  beta  rays  are  slightly  more  so, 
while  the  gamma  rays  pass  through  a  sheet  of  lead  one  centimeter 
thick,  the  human  body,  the  walls  of  a  house,  etc.  The  relationship 
of  the  radiation  of  these  various  rays  may  be  expressed  by  the 
equation,  1 :100 :10,000. 

Methods  of  Estimating  and  Measuring  Radio-Active  Emanation. 
— Until  recently,  the  strength  of  radio-active  substances  has  usu- 
ally been  expressed  in  Mache  units — a  Mache  unit  representing 
0.001  electrostatic  unit  as  measured  by  the  amperemeter  and  mul- 
tiplied by  1,000.  At  present,  to  standardize  this  somewhat  arbitrary 
method,  the  term  "curie"  is  employed.  A  curie  represents  the 
amount  of  emanation  in  equilibrium  with  one  gram  of  radium;  a 
" microcurie, "  i.e.,  one  millionth  of  a  curie,  is  the  amount  of  emana- 
tion in  equilibrium  with  0.001  milligram  radium.  A  microcurie 
equals  about  2,700  Mache  units.  The  various  rays  emanated  by 
radio-active  substances  act  upon  photographic  plates,  they  pro- 
duce fluorescence  in  certain  bodies,  they  electrify  gases,  and  they 
produce  measurable  quantities  of  heat.  Upon  these  factors  are 
based  the  various  methods  of  measuring  the  radio-active  emana- 
tion, i.  e.,  the  radiographic,  the  fluoroscopic,  the  electric,  and  the 
thermnc.  Various  ingenious  apparatus  have  been  devised  to  ac- 
complish these  purposes. 

Biologic  and  Physiologic  Action  of  Radio-Active  Substances. — 
Every  living  cell,  when  subjected  to  radium  emanation,  is  in- 
fluenced by  it;  however,  the  reaction  of  the  cell  depends  upon  its 
specific  nature  and  upon  the  kind  of  rays  employed.     In  conse- 


470  PHYSICAL   THERAPEUTICS 

quence,  certain  tissues  are  more  easily  amenable  to  the  rays  than 
others.  Nervous  tissue  reacts  most  energetically,  while  intestinal 
and  serous  tissues  are  far  less  strongly  influenced.  Muscle  tissue 
is  the  least  reactive.  Connective  tissue,  when  subjected  to  the  rays, 
is  readily  stimulated  to  proliferation.  Histologic  examination  in- 
dicates that  the  typical  phenomena  of  inflammation,  with  their 
long  chain  of  changes,  i.e.,  from  an  early  hyperemia  to  the  final 
necrosis,  may  be  produced  at  will.  The  internal  organs  react  in 
various  ways;  readily  influenced  are  lymphoid  tissues,  especially 
the  spleen,  less  so  the  kidneys,  and  still  less  the  salivary  glands 
and  mucous  membrane.  No  living  tissue  will  stand  the  prolonged 
exposure  to  the  rays  without  showing  some  definite  change,  and  it 
is  immaterial  whether  the  tissue  is  of  animal  or  vegetable  origin. 
Ferments,  on  an  average,  are  slightly  activated.  Saliva  ferments 
are  usually  at  first  slightly  paralyzed  and  later  activated;  the  re- 
sults obtained,  however,  are  so  very  variable  that  little  significance 
can  be  placed  on  these  observations.  Low-type  organisms,  i.e., 
bacteria,  protozoa,  etc.,  are  comparatively  very  slightly  influenced 
by  radiation.  Upon  pathological  tissues  the  effect  of  the  rays  is 
much  more  pronounced  than  upon  normal  structure,  hence  the 
great  significance  of  the  rays  in  the  treatment  of  diseases.  As 
stated  by  Strieker,  pathological  tissues  react  to  the  gamma  rays 
according  to  the  following  scale :  Leukemic  tissues,  mycosis, 
eczema,  sarcoma,  carcinoma,  lupus,  tubercular  ulcers,  lipoma, 
myoma,  and  fibroma.  The  physiologic  effect,  as  Von  Norden  ex- 
presses it,  results  in  an  internal  electric  ionization  of  the  tissues. 
So  far,  no  danger  from  the  application  of  small  doses  of  emanation 
have  been  observed ;  large  doses  are  productive  of  destructive  re- 
sults. From  a  therapeutic  point  of  view,  innumerable  diseases 
have  been  subjected  to  the  effects  of  radium  emanation.  In  due 
time  it  was  found  that  specific  results  were  obtained  in  certain 
forms  of  skin  diseases,  including  neoplasms,  in  disturbances  of 
metabolism,  especially  gout,  and  in  painful  alterations  of  the  nerv- 
ous system,  i.e.,  neuralgia,  locomotor  ataxia,  etc. 

Methods  of  Application  of  Eadio-Active  Substances.. — Of  the 
various  radio-active  substances,  radium  and  mesothorium  in  nu- 
merous modifications  are  the  principal  elements  employed  thera- 
peutically at  present.  The  salts  of  these  elements  may  be  preserved 
in  small  metal,  ebonite,  or  other  suitable  containers,  covered  by 
a  filter  usuallv  consisting  of  a  thin  sheet  of   mica   or   aluminum. 


LIGHT  THERAPY  471 

Various-shaped  tubes,  boxes,  sounds,  compresses,  etc.,  are  avail- 
able so  as  to  conform  to  the  various  types  of  body  surfaces  and 
cavities.  If  a  radio-active  substance  is  to  be  administered  in  the 
form  of  gas  emanation,  it  is  preferably  carried  out  in  an  inhala- 
torium.  Many  of  the  well-known  sanatoriums  of  Europe  and  the 
United  States  are  at  present  provided  with  such  radium  emanation 
inhalatoriums.  For  the  internal  administration  of  radium  emana- 
tion, water  artificially  charged  with  radio-active  gases  or  with 
the  dissolved  salts,  or  natural  springs  containing  radio-active  sub- 
stances are  chiefly  employed.  For  the  charging  of  water  with 
radium  emanation,  various  methods  are  in  vogue.  The  water  may 
be  charged  by  direct  solution  of  a  soluble  radium  salt,  i.e.,  the 
bromid  or  the  chlorid,  or  by  submerging  a  very  finely  powdered 
insoluble  salt,  i.e.,  the  sulfate.  To  present  as  large  a  surface  as 
possible,  the  insoluble  radium  salts  are  employed  in  various  modi- 
fications. They  may  be  precipitated  upon  asbestos  in  a  porous 
cell,  they  may  be  mixed  with  charcoal  and  formed  into  slabs,  they 
may  be  mixed  with  cement  and  formed  into  balls,  and  lastly,  they 
may  be  mixed  with  clay  and  fired.  Most  of  these  processes  of  sub- 
dividing radium  salts  are  protected  by  patents.  The  "life"  of 
these  various  modifications  of  radio-activity  is  usually  very  pro- 
longed; the  fireclay  rods,  it  is  estimated,  may  be  used  seventeen 
hundred  years,  and  still  have  one-half  of  their  radium  content 
available. 

For  many  centuries  it  has  been  known  that  the  water  of  certain 
mineral  spas  is  endowed  with  peculiar  therapeutic  qualities  which 
cannot  be  attributed  to  the  organic  or  inorganic  constituents  of 
these  spas.  It  was  found  that  certain  artificially  compounded 
mineral  waters  prepared  according  to  formulas  obtained  from 
most  carefully  conducted  analyses  will  not  produce  the  same  thera- 
peutic effects  as  the  water  employed  at  the  respective  spas.  While 
climatic  conditions,  change  of  environment,  and  similar  factors 
no  doubt  play  an  important  role  in  balneologic  therapeutics,  the 
fact  remains,  however,  that  the  water  of  certain  spas,  when  drunk 
at  the  springs,  exercises  some  peculiar  beneficial  effect  on  the  sick. 
To  explain  these  curious  properties,  folk-lore  has  endowed  certain 
springs  with  mystic  spirits,  the  "Brunnengeist,"  the  "spirit  of 
the  spring,"  as  it  has  been  appropriately  designated  in  bygone 
days  by  the  Germans.  Soon  after  the  emanation  of  radium  had 
become  an  established  fact,  investigation  was  carried  on  in  the 


472  PHYSICAL   THERAPEUTICS 

hope  of  finding  similar  possibilities  possessed  by  the  various  spas, 
and  it  was  discovered  that  many  of  the  famous  watering  resorts 
owe  their  renoAvn  in  a  large  measure  to  the  presence  of  radium 
emanation  in  their  spas.  The  more  important  watering  resorts 
of  Europe  containing  emanation  are:  Bath,  Baden-Baden,  Gastein, 
Landeck,  Joachimstal,  etc. 

Therapeutic  Application. — Eadium  was  introduced  into  dental 
therapeutics  in  1912,  by  M.  Levy,  of  Berlin.  Aside  from  his  nu- 
merous publications,  the  writings  of  Walkhoff,  Trauner,  Mamlok, 
Leger-Dorez,  Warnekros,  and  many  others  are  available  to  the 
inquiring  student.  According  to  Levy,  the  following  oral  diseases 
have  been  subjected  to  radium  emanation:  Psoriasis  of  the  oral 
mucous  membrane,  pyorrhea  alveolaris,  loosening  of  the  teeth  with- 
out the  presence  of  pus,  marginal  gingivitis,  leukoplakia,  chronic 
aphthae,  fistulas,  and  ulcerative  stomatitis  caused  by  gout.  The 
therapeutic  application  of  radio-active  substances  about  the  mouth 
may  be  accomplished  by  utilizing  the  following  methods  and  means : 
The  drink  cure,  mouth-washes,  tooth-pastes,  compresses,  injec- 
tions, irrigation,  inhalation,  and  finally,  variable  combinations  of 
these  procedures.  The  drink  cure  and  the  application  of  the 
mouth-washes  are  probably  the  two  most  prominent  means  of 
utilizing  radium  emanation  for  such  purposes;  the  other  enum- 
erated methods  are  of  questionable  value.  The  technique  of  the 
various  methods  is  comparatively  simple.  As  a  drink  cure,  Levy 
recommends  the  following  procedure :  Water  charged  with  emana- 
tion, or  water  containing  a  specific  quantity  of  a  soluble  radium 
salt  may  be  used.  The  radium  content  should  correspond  to 
about  1,000  to  3,000  Mache  units  per  day,  although  higher  con- 
centrations have  been  used  with  no  deleterious  side-effects.  Every 
twenty  to  thirty  minutes  during  the  two  or  three  hours  follow- 
ing the  three  main  meals,  a  small  quantity  of  the  charged  water 
should  be  taken.  The  object  is  to  furnish  the  organism  with  small 
quantities  of  the  products  of  decomposition  of  radium,  which  are 
slowly  absorbed.  In  due  time  they  reach  the  blood  current  and 
finally  are  eliminated,  primarily  through  the  lungs  and  to  a  less 
extent  by  the  urine,  the  skin,  perspiration,  and  the  saliva.  Within 
twenty  minutes  after  partaking  of  600  Mache  units,  radium  emana- 
tion has  been  shown  to  be  present  in  the  saliva.  As  a  gargle, 
Trauner  recommends  the  folloAving  procedure:  A  quart  of  water 
containing  about  375  Mache  units  forms  the  basis  of  the  mouth- 


LIGHT   THERAPY  473 

wash.  Of  this  solution,  the  patient  uses  two  glassfuls  (about  10 
fluidounees  each)  per  day  as  a  mouth- wash,  observing  the  follow- 
ing precautions:  Every  dose  of  the  solution — which  should  not 
be  too  large,  so  as  to  find  ample  room  in  the  mouth — has  to  be 
worked  forcibly  between  the  cheeks  and  the  teeth  for  at  least  a 
minute  and  a  half,  so  as  to  de-emanize  the  water.  The  water  should 
then  be  removed  from  the  mouth  slowly  and  in  a  thin  stream.  The 
emanation  will  separate  from  the  water  and  precipitate  itself  upon 
the  mucous  surfaces  of  the  mouth.  From  twenty  to  thirty  minutes 
are  necessary  to  use  up  the  content  of  a  glassful  of  the  solution. 
After  the  gargling,  the  patient  should  not  eat  or  drink,  and  if 
possible  should  not  speak,  for  at  least  one  or  better  two  hours,  to 
retain  the  gaseous  emanation  in  the  mouth.  With  this  simple  pro- 
cedure Trauner  claims  to  have  obtained  most  remarkable  results. 
The  formation  of  pus  and  subjective  symptoms  are  checked  in 
two  or  three  days,  remaining  only,  and  to  a  milder  degree,  upon 
those  places  where  accumulations  of  calcareous  deposits  are  pres- 
ent. The  tartar  has  to  be  removed  thoroughly,  and  at  future  sit- 
tings careful  examination  has  to  be  made  for  remnants  of  tartar, 
which  represent  a  constant  and  sure  source  of  pus  production. 
Large-sized  pockets  are  successfully  treated  by  syringing  with 
two  cubic  centimeters  of  a  concentrated  emanation  solution. 

Radium  treatment  is  slowly  settling  down  to  the  specific  phase 
in  medical  and  dental  practice  to  which  undoubtedly  it  is  en- 
titled. The  two  dental  institutes  which  have  primarily  investi- 
gated radium  therapy  are  the  institutes  of  the  University  of  Ber- 
lin and  of  Graz.  At  the  Berlin  Institute,  Zahnarzt  Mamlok,  and 
at  Graz  Professor  Trauner,  have  carried  out  extensive  investiga- 
tions on  the  subject.  Trauner  is  still  an  ardent  advocate  of 
radium  therapy,  and  he  is  convinced  that  its  infiuence  is  very 
marked  in  the  treatment  of  inflammatory  conditions  of  the  oral 
mucous  membrane.  On  the  other  hand,  Mamlok  is  rather  skepti- 
cal at  present,  and  he  sums  up  his  experience  by  stating  that  the 
prolonged  utilization  of  water  charged  with  radium  emanation 
has  a  tendency  to  lower  the  virulence  of  the  ordinary  pus  bacteria 
usually  found  in  inflammatory  conditions  of  the  mouth.  He  has 
obtained  good  results  in  the  treatment  of  pyorrhea  alveolaris  by 
combining  the  following  procedures :  Careful  removal  of  all  tartar 
deposits,  establishing  perfect  occlusion,  splinting  of  loose  teeth, 
application   of   radio-active   substances,    and   rigid   oral   hygiene. 


474  PHYSICAL   THERAPEUTICS 

Patients  who  suffered  with  pain  in  connection  with  their  dental 
ailments  are  unanimous  in  their  statements  that  washing  with 
radium-charged  water  relieves  this  condition,  like  "magic,"  as 
they  express  it.  Of  the  many  other  benefits  claimed  by  dental 
practitioners  and  patients  alike  relative  to  the  therapeutic  effects 
of  radium  mouth-washes,  pastes,  etc.,  the  writer  is  extremely  skep- 
tical. He  has  not  been  able  to  observe  any  special  value  derived 
from  such  procedures.  In  a  number  of  counter-tests,  in  which  a 
warm  physiologic  salt  solution  was  substituted  for  the  radium 
preparations,  the  comparative  results  obtained  were  equally  as 
good.  In  certain  chronic  and  malignant  diseases  of  the  oral  cav- 
ity and  its  adnexa,  i.e.,  carcinoma,  epithelioma,  leucoplakia,  etc., 
the  treatment  with  radium  seems  to  be  followed  by  marked  benefit. 
As  stated  above,  radium  seems  to  be  entitled  to  a  legitimate  place 
in  general  therapeutics.  So  far  as  its  application  in  the  treatment 
of  oral  diseases,  especially  pyorrhea  alveolaris,  is  concerned — for 
which  it  has  received  the  bulk  of  its  indorsement — at  present  no 
positive  results  can  be  recorded. 

HEAT  AND  COLD. 

Heat  and  cold  are  frequently  referred  to  as  distinct  entities,  but 
in  reality  they  are  merely  relative  terms,  expressing  the  variations 
above  and  below  normal  temperature.  By  the  latter  term  the 
temperature  of  the  human  body— about  98.4°  F.  (36.9°  C.)  — 
is  meant,  and  is  taken  as  the  average  caloric  indicator. 

Heat  is  applied  in  two  forms — dry  heat  and  wet,  or  moist,  heat. 
The  physiologic  effect  of  both  is  the  same,  and  they  produce  a 
pronounced  active  hyperemia,  with  all  its  phenomena.  Dry  heat 
can  be  borne  by  the  body  at  a  very  much  higher  degree  than  moist 
heat.  In  the  Turkish  bath  temperatures  as  high  as  140  to  150° 
F.  (60  to  66°  C.)  are  frequently  reached,  while  moist  heat  in  the 
form  of  a  poultice  should  be  limited  to  105  to  110°  F.  (40  to  43° 
C).  Above  this  temperature  moist  heat  is  injurious  to  the  soft 
tissues.  The  body  protects  itself  against  great  heat  by  the  free 
evaporation  of  profuse  perspiration  and  the  powerfully  accelerated 
blood  stream  within  the  heated  area.  Dry  heat  is  conveyed  to  the 
tissues  through  the  air,  and,  as  air  is  a  very  poor  conductor,  much 
of  the  heat  is  lost ;  while  moist  heat  is  kept  in  intimate  contact  with 
the  tissues,  and  is  held  there  for  a  definite  period.    The  continu- 


HEAT   AND    COLD  475 

ous  application  of  heat  on  pathologically  altered  tissues  produces 
definite  changes  in  the  structures.  The  resulting  increased  osmotic 
pressure  exerts  a  powerful  influence  on  the  centrifugal  flow  of 
the  lymph,  and  the  products  of  the  early  stages  of  inflammation 
are  carried  away  from  the  center  toward  the  periphery,  to  be 
poured  into  the  circulating  blood  stream  or  otherwise  disposed  of. 
If  pus  is  about  to  gather,  the  heat  will  materially  assist  in  the  ready 
breaking  down  of  the  affected  structures,  and  will  help  to  "ripen" 
the  abscess. 

The  general  effects  of  cold  on  the  tissues  manifest  themselves 
in  lowering  the  temperature,  diminishing  the  sensibility,  and 
contracting  tissues  and  vessels,  thereby  reducing  the  volume  of 
these  parts.  Cold  continuously  applied  benumbs  the  part,  and 
produces  in  due  time  a  definite  local  anesthesia.  Cold,  when  locally 
and  continuously  applied  in  the  form  of  an  ice  pack,  cold  water 
coil,  towels  wrung  out  in  iced  water,  etc.,  causes  a  temporary 
inhibition  of  inflammation  in  its  very  early  stages.  Its  anti- 
phlogistic action  is  manifested  by  retarding  circulation  and  in- 
hibiting the  emigration  of  the  leucocytes.  As  soon  as  the  cold 
application  is  removed,  the  inflammatory  process  starts  with  re- 
newed activity.  When  applied  to  an  infiltrated  area,  it  produces 
anemia  and  increases  the  osmotic  pressure  within  the  edematous 
field  surrounding  the  focus  of  inflammation,  which  results  in 
severe  pain  and,  under  certain  conditions,  in  distinctly  dangerous 
symptoms — as,  for  instance,  in  passive  hyperemia  or  stasis  of 
the  pharynx. 

Therapeutic  Applications. 

Heat  and  cold  are  applied  for  general  purposes  in  the  many 
varieties  of  the  bath,  while  locally  any  neutral  material  which 
will  convey  and  retain  either  one  for  a  sufficient  length  of  time 
may  be  used.  Apparently  there  exists  quite  a  diversity  of  opinion 
relative  to  the  use  of  moist  heat,  dry  heat,  and  cold.  Both  forms 
of  heat,  locally  applied,  are  productive  of  the  same  results.  They 
induce  intense  active  hyperemia,  and  apparently  it  makes  little 
difference  what  form,  of  heat  is  employed.  The  choice  between 
heat  and  cold,  in  general  conditions,  is  largely  governed  by  the 
wish  of  the  patient,  except  in  fever,  and  the  patient  will  usually 
assert  that  one  of  the  two  is  more  agreeable  to  him.    If  we  are 


476  PHYSICAL   THERAPEUTICS 

dealing  with  a  pericemental  inllammation  and  the  consequential 
formation  of  an  alveolar  abscess,  the  conditions  for  the  require- 
ment of  heat  and  cold  can  be  more  definitely  outlined.  Clinical 
experience  has  taught  that  in  the  early  stages  of  pericemental  in- 
flammation ice  chips  held  in  the  mouth  are  useful  in  retarding  the 
process  of  inflammation  and  mitigating  the  pain.  If  the  infiltra- 
tion of  the  tissues  has  proceeded  to  such  an  extent  as  to  indicate 
possible  pus  formation,  a  hot  poultice  placed  directly  over  the 
offending  tooth  and  covering  the  entire  inflamed  area,  applied 
in  the  oral  cavity,  is  extremely  serviceable. 

Poultices  (eataplasma,  L. ;  cataplasme,  F. ;  Breiumschlag,  G.) 
are  soft,  moist  applications,  usually  employed  hot,  but  sometimes 
cold;  and  occasionally  they  may  contain  drugs  indicated  to  exert 
some  specific  action.  Poultices  furnish  more  or  less  constant  heat 
and  moisture,  and  thereby  relax  the  skin,  thus  favoring  swelling. 


Fig.  96. 
Electric  thermaphone  pad. 

but  lessening  tension  of  the  tissues.  Whenever  a  hot  poultice  is 
employed,  it  should  always  cover  the  field  of  inflammation  in  its 
entirety,  or  it  may  be  applied  in  the  form  of  a  broad  ring.  It 
should  never  be  so  small  as  to  cover  the  center  of  inflammation 
only,  as  then  the  pain  is  certain  to  increase.  A  hot  poultice  has 
no  place  on  an  opened  or  a  septic  wound,  as  it  would  practically 
seal  up  the  infected  focus,  and  the  pent  up  infection  would  rapidly 
involve  the  surrounding  tissues. 

A  hot  poultice  placed  externally  on  the  cheek  in  pericemental 
infiltration  is  always  dangerous,  as  it  will  assist  in  drawing  the 
pus  to  the  surface,  which  means  an  external  opening,  with  the 
possibility  of  a  disfiguring  scar.  A  serviceable  poultice  to  be 
applied  over  a  tooth,  and  one  which  will  retain  heat  for  a  suf- 
ficient time,  is  preferably  applied  in  the  form  of  raisins  or  figs 


HEAT    AND    COLD  477 

cut  into  slices  and  boiled  in  water.  These  slices  should  be  ap- 
plied as  hot  as  can  be  borne,  and  renewed  as  often  as  necessity 
demands. 

For  the  application  of  dry  heat  on  external  body  surfaces  many 
forms  of  heat  carriers  are  employed.  The  heated  brick,  hot-water 
bottle,  heated  salt  bags,  the  Japanese  stove,  and  many  other  means 
are  utilized  to  retain  heat  for  a  limited  time.  A  permanent  source 
of  heat  is  obtained  by  wrapping  an  electric  light  globe  in  suitable 
material  (cotton),  and  placing  it  against  the  diseased  part.  To 
avoid  the  danger  of  breaking  the  globe,  an  electric  heating  pad, 
known  as  a  thermaphone,  has  recently  been  placed  on  the  market, 
which,  from  all  appearances,  seems  to  serve  its  purpose  well. 

Within  recent  years  the  introduction  of  the  so-called  clay  poul- 
tices, under  various  fanciful  names,  have  been  much  discussed  in 
current  literature.  From  the  ludicrous  advertisements  of  the 
makers  of  the  various  clay  poultices  the  practitioner  may  be 
placed  under  the  impression  that  this  new  panacea  is  far  superior 
to  any  other  form  of  poultice.  One  preparation  carries  the  fol- 
lowing teleologically  constructed  explanation  regarding  its  action : 

"The  skin  may  be  regarded  as  a  permeable  membrane  separat- 
ing two  fluids  of  different  densities — the  blood  and  the  clay  poul- 
tice. If  the  *  *  *  (clay  poultice)  is  applied  hot  under  such  con- 
ditions, something  definite  happens,  and  that  scientifically — an 
interchange  of  fluids,  most  marked  toward  the  clay  poultice ;  hence 
the  deduction  that  the  mixture  acts  through  reflex  action  and 
dialysis,  the  latter  scientifically  including  the  physical  processes 
of  exosmosis  and  endosmosis,  and  that  the  blood  pressure  from  the 
overworked  part  is  reduced,  the  muscular  and  nerve  resistances 
are  relaxed,  and  refreshing  sleep  is  invited." 

Eoth^  and,  very  recently,  Pilchen^  have  experimentally  dem- 
onstrated that  an  old-fashioned  flaxseed  poultice  holds  the  heat 
markedly  longer  than  its  modern  substitute,  and  that,  "further- 
more, one  is  immediately  convinced  that  no  process  of  osmosis  or 
endosmosis  is  involved,  for  the  much  simpler  explanation  suffices 
that  the  gain  of  weight  is  due  to  the  absorption  by  the  clay  poul- 
tice of  the  increased  local  perspiration,  which  latter  in  turn  is 
due  to  the  local  application  of  continuous  heat.  Indeed,  the  pre- 
vailing scientific  opinion  is  that  nothing  passes  from  within  out- 
ward through  the  intact  skin  except  by  way  of  the  sweat  glands." 


>  Roth:  Journal  American   Medical  Association,  April   15,   1905,  p.   1185. 
'Pilchen:  Journal  American  Medical  Association,  March  6,   1909,  p.  752. 


478  PHYSICAL   THERAPEUTICS 

PLUGGING  BONE  CAVITIES  WITH  INERT  OR  MEDICATED 

SUBSTANCES. 

The  filling  of  cavities  caused  Ijy  the  destruction  of  bone  with 
inert  or  medicated  substances  is  materially  simplified  by  employ- 
ing the  ingenious  methods  outlined  by  the  late  Mosetig-Moorhof. 
Mosetig^  divides  the  substances  that  are  used  for  this  purpose  into 
absorbable  and  nonabsorbable  materials.  The  absorbable  ma- 
terials are  again  divided  into  autoplastic  and  heteroplastic  sub- 
stances. The  filling  of  bone  cavities  by  the  Mosetig  process  is  ac- 
complished by  using  only  heteroplastic  substances.  In  the 
practice  of  general  surgery,  bone  filling  by  divers  materials  is 
utilized  to  quite  an  extent,  and  the  Macewen  operation,  Senn's 
bone  grafting,  etc.,  are  examples  of  such  procedures.  Mosetig  ad- 
vised the  use  of  a  solid,  but  readily  absorbable,  material  which  can 
be  easily  introduced  into  the  "dead  spaces"  in  a  liquid  form,  so 
as  to  fill  all  the  nidi  and  crevices  that  are  liable  to  remain  after 
a  bone  operation  or  after  bone  absorption.  The  material  advo- 
cated by  Mosetig  consists  of  a  mixture  of  iodoform,  spermaceti, 
and  oil  of  sesame,  and  is  known  in  general  surgery  as  "bone 
plombe.  "^  Mayrhofer^  recognized  the  value  of  the  Mosetig  bone 
plombe  in  its  relation  to  dental  surgery,  and  he  advocated  its  use 
in  a  modified  form  in  1905.  The  dental  indications  for  this  pro- 
cedure are  manifold.  It  is  especially  serviceable  after  root  ampu- 
tations, in  abscess  cavities  with  or  without  fistulas,  in  bone  cavities 
resulting  from  the  various  causes  of  necrosis,  in  the  treatment  of 
pyorrhea  alveolaris,  to  some  extent  in  the  treatment  of  chronic 
empyema  of  the  antrum,  etc.  In  applying  this  method  of  treat- 
ment a  few  salient  factors  are  essential,  and  their  strict  recogni- 
tion is  of  the  utmost  importance  for  the  success  of  the  treatment. 
The'  cavity  which  is  to  be  filled  with  the  bone  plombe  must  be 
absolutely  dry.  This  can  be  readily  accomplished  by  packing  the 
cavity  with  strips  of  gauze,  which  are  removed  at  the  very  moment 
the  liquefied  plombe  is  put  in  place.    The  hot  air  blast  is  often  of 


^Mosetig-Moorhof:   Wiener   Klinische   Wochenschrift,    1906,   No.   44. 

*  Plombe  is  the  German  term  for  the  filling  of  a  tooth,  and  Plombierung  indicates  the 
process  of  .filling  teeth.  Plombe  is  derived  from  plumbum,  the  Latin  term  for  lead,  a  ma- 
terial which  at  one  time  was  in  general  use  for  stopping  cavities  in  teeth.  The  term  bone 
plombe  has  been  generally  accepted  by  American  and  English  writers  as  a  special,  descrip- 
tive term  for  the  Mosetig  process  of  filling  the  dead  spaces  after  bone  operations. 

*Mayrhofer:  Osterreich-Ungarische  Vierteljahrsschrift  fur  Zahnheilkunde,  1905,  No.  2; 
1906,  No.  3:  1907,  No.  1. 


PLUGGING   BONE    CAVITIES 


479 


great  assistance  for  such  work.  The  plombe  must  completely 
fill  the  cavity — that  is,  it  must  not  contain  air  spaces.  By  press- 
ing the  semisolid  material  into  place  with  tampons  of  gauze,  and 
by  using  a  heated  pointed  instrument,  a  solid  filling  is  readily 
obtained.  The  filling  in  the  bone  cavity  after  a  root  amputa- 
tion, etc.,  should  be  covered  with  the  primarily  lifted  up  muco- 
periosteum,  while  in  the  case  of  fistulas  no  further  protection  is 
necessary.  Mayrhofer  advocates  holding  the  periosteal  fiap  in 
position  by  a  suture.  We  have  never  had  occasion  to  use  a  suture 
for  this  purpose.  After  the  flap  is  replaced,  the  lip  or  cheek 
exercise  sufficient  pressure  to  hold  it  in  correct  position.  In  1901 
Bohm^  constructed  a  small  syringe  with  which  it  is  possible  to 


Fig.  97. 
Bohm's  syringe  for  bone  plombe. 

deposit  the  medicated  bone  plombe  in  the  form  of  a  bougie  in 
an  even  manner  in  any  crevice  or  corner  which  can  not  be  reached 
otherwise.  This  little  syringe  is  supplied  with  a  number  of  can- 
nulas of  various  shapes,  and  is  especially  of  service  in  the  treat- 
ment of  chronic  alveolar  abscesses.  This  little  device  has  been 
successfully  employed  for  such  work  by  Bohm,  Misch,^  Lies,''  and 
others. 

The  technique  of  placing  the  plombe  is  simple.     In  the  early 
days  of  the  operation,  Mayrhofer  used  a  hot  water  jacket  syringe, 


»Bohm:  Zahnarztlichc  Rundschau,   1901,  No.   451. 

»Misch:  Osterreichische  Zeitschrift  fur  Stomatologie,  1904,  No.  4. 

•Lies:  Deutsche  Zahnarztliche  Wochenschrift,   1903,  No.  4. 


480 


PHYSICAL   THERAPEUTICS 


but  at  present  he  relies  upon  a  wax  spatula  and  a  few  pointed  in- 
struments. Beck  advises  an  all-metal  sj'ringe  or  a  collapsible 
tube,  fitted  with  a  flexible  cannula  having  a  fine,  tapering  point 
made  of  pure  silver.  In  all  cavities  that  afford  ready  access  an 
ordinary  wax  spoon,   a   pointed  metallic  instrument,   and  a  few 


Fig.  98. 

Collapsible   tube  for  bone  plombe.     A  flexible  cannula  attached  to   a   collapsible  tube  for 

placing  the  bone  plombe. 

gauze  tampons  answer  the  purpose  sufficiently  well.  For  cavities 
having  no  direct  access,  a  syringe  with  a  curved  cannula,  or  a  col- 
lapsible tube  with  a  flexible  cannula,  is  necessary.  For  the  fill- 
ing of  very  narrow  cavities — fistulous  tracts,  pockets  of  pyorrhea 


PLUGGING    BONE    CAVITIES 


481 


alveolai'is,  etc.— the  Bohm  syringe  is  very  serviceable.  The 
syringe  is  applied  with  various  bent  cannulas,  which  readily  reach 
any  part  of  the  mouth.    For  the  treatment  of  an  abscess,  a  small 


Fig.  99. 

A  hypodermic  syringe  prepared  for  bone  plombe.     A  flexible  cannula  is  attached  to  the 
hypodermic  syringe  for  the  purpose  of  conveying  the  bone  plombe  to  a  root  canal  of  a  tooth. 


amount  of  slightly  warmed,  but  not  liquefied,  paste  is  rolled  into 
a  cylinder  (a  bougie),  which  is  inserted  into  the  Bohm  syringe 
supplied  with  the  proper  cannula,  and  a  slight  pressure  is  asserted 


482  PHYSICAL   THERAPEUTICS 

upon  the  piston  until  the  paste  appears  at  the  point  of  the  can- 
nula. A  small  piece  of  rubber  tubing  or  temporary  stopping  is 
now  placed  about  the  tip  of  the  cannula  to  form  an  air-tight  joint, 
and  the  syringe  is  tightly  inserted  into  the  root  canal.  Slight,  but 
continuous,  pressure  is  now  applied  to  the  piston  until  the  bone 
filling  appears  at  the  mouth  of  the  fistula.  The  canal  is  sealed 
with  temporary  stopping.  If  necessary,  the  treatment  is  repeated 
in  a  few  days. 

The  bone  filling  consists  of  an  unctuous  base,  to  which  some 
strong  antiseptic  has  been  added.  The  original  Mosetig  bone 
plombe  was  prepared  by  melting  together  equal  parts  of  oil  of 
sesame  (oil  of  benne)  and  spermaceti,  filtering  and  sterilizing 
the  liquid  in  a  water  bath,  and  then  pouring  60  grams  of  the 


Fig.  100. 
A  large  cavity  in  the  mandible  filled  with  bone  plombe. 

hot  mixture  into  a  large  dry  bottle  containing  40  grams  of  finely 
pulverized  iodoform,  and  shaking  constantly  until  the  mass 
hardens.  For  dental  purposes,  Mayrhofer  advises  the  follow- 
ing modified  formula: 

Spermaceti    30  drams   (120  Gm.) 

Oil  of  sesarre 15  drams   (  60  C.c.) 

Iodoform     10  drams   (  40  Gm.) 

This  combination  produces  a  more  durable  filling,  as  it  is  of  a 
harder  consistency  than  the  original  formula.  The  iodoform  odor 
is  extremely  disagreeable,  and  even  nauseating,  to  some  patients. 
By  substituting  an  odorless  iodin  compound — as  europhen,  vio- 


PLUGGING    BONE    CAVITIES 


483 


form,  aristol,  etc. — this  objection  is  readily  overcome  without 
materially  lessening  the  antiseptic  qualities  of  the  filling.  The 
ready-made  filling  is  kept  in  small  well-stoppered  bottles,  test 
tubes,  or  collapsible  tubes.  By  placing  the  bottle  or  tube  in  a 
container  filled  with  hot  water,  it  is  heated  to  the  point  of  lique- 
faction, stirred,  and  is  then  ready  for  use. 

Recently  Rudolph  Beck^  has  described  a  similar  filling  which 
was  suggested  to  him  by  Emil  and  Joseph  Beck.     The  latter  em- 


Fig.    101. 

Manifestations  of  bismuth  poisoning  in  the  mouth  following  bismuth  paste  injection. 
(Case  of  Dr.   E.  B.   Freilich.'') 

ploy  this  paste  in  sinuses  of  joints  and    abscess    cavities.      The 

Beck  bone  paste  is  composed  as  follows: 

Bismuth  subnitrate 6  drams  (24  Gm.) 

White  wax  1  dram     (  4  Gm.) 

Paraffin  1  dram     (  4  Gm.) 

Vaselin 12  drams  (48  Gm.) 

The  ingredients  are  mixed  by  boiling. 

The  technique  of  applying  the  Beck  paste  is  similar  to  Mayr- 
hofer's  method-  Rudolph  Beck  and,  recently,  Warner  speak 
very  highly  of  its  value  in  dental  surgery.  Rudolph  Beck  recom- 
mends this  paste  especially  as  a  means  of  treating  pyorrhea  alveo- 
laris.    He  injects  the  liquefied  paste  with  gentle,  but  steady,  pres- 

^Rudolph  Beck:  Dental  Review,  1909,  No.  1. 

»Freilich:  Journal   American   Medical   Association,    1917,   p.    111. 


484  PHYSICAL   THERAPEUTICS 

sure  into  the  pus  pockets  about  the  teeth,  so  as  to  reach  the  very 
bottom  of  every  crevice.  There  are  certain  objections  to  the  Beck 
paste  which  render  it  of  less  value  as  compared  with  Myrhofer's 
modification  of  the  Mosetig  plombe.  The  principal  objection  is 
the  danger  arising  from  bismuth  intoxication.  Within  the  last 
few  years  a  goodly  number  of  serious  results  arising  from  the  ab- 
sorption of  this  paste  have  been  reported,  even  from  relatively 
small  quantities  as  required  for  dental  purposes,  so  that  at  pres- 
ent its  use  is  largely  abolished.    Horsley's  bone  wax,  consisting  of: 

Phenol  crystals 1  dram     (    4  Gm.) 

Olive   oil    2  drams  (    8    C.c.) 

Wax 7  drams  (  28  Gm.) 

is  employed  for  the  same  purpose  by  many  surgeons  with  satis- 
factory results.  A  paste  made  of  zinc  oxid  and  petrolatum  has 
also  been  much  lauded.  The  rationale  of  the  bone  plugging  com- 
pound seems  to  consist  in  completely  obliterating  the  cavity  with 
a  sterile,  absorbable  plug.  In  an  extensive  necrosis  of  the  mandible 
the  author  has  injected  about  1^  ounces  (40  Gm.)  of  Mayrhofer's 
iodoform  paste,  the  largest  quantity  ever  used  by  him  for  a  single 
operation.  There  were  no  systemic  effects  produced  by  the  slow 
absorption  of  the  paste,  and  within  four  months  the  destroyed 
tissues  were  partially  replaced  by  new  bone  formation. 

ELECTRO-STERILIZATION. 

The  most  serious  question  that  confronts  the  dental  profession 
today — and  for  that  matter  confronted  it  in  the  past — is  that 
which  is  involved  in  the  problem  of  establishing  absolute  sterility 
of  an  infected  root  canal.  The  disposal  of  this  problem  in  a  truly 
scientific  manner  necessitates  the  determination  of  established 
sterility  by  bacteriologic  tests  in  each  individual  case.  While  the 
writer  realizes  that  the  carrying  out  of  such  procedures  in  the 
average  dental  office  of  today  will  meet  with  numerous  difficulties, 
due  to  the  fact  that  the  older  members  of  our  profession  have  not 
had  sufficient  training  in  these  directions,  nevertheless  there  exists 
no  valid  reason  why  it  should  not  be  done  for  the  practitioner 
through  a  laboratory.  The  time  is  not  far  distant  when  the  public 
will  demand  a  laboratory  diagnosis  of  serious  root  canal  infections 
for  the  same  reason  that  a  bacteriologic  examination  of  a  diph- 
theritic throat  is  demanded  at  present.    Since  the  sequences  of  im- 


ELECTRO-STERILIZATION  485 

perfect  root  canal  sterilization  in  the  form  of  focal  infections  re- 
sulting in  metastatic  disturbances  of  distant  organs  are  of  com- 
mon occurrence,  it  must  follow  that  our  present  methods  of  estab- 
lishing perfect  sterility  of  a  root  canal  are  inadequate. 

The  treatment  of  an  infected  root  canal  resolves  itself  into  three 
definite  phases — the  mechanical,  the  chemic,  and  the  therapeutic 
procedures.  Mechanical  manipulations  are  intended  to  dispose  of 
the  debris  of  the  dead  pulp,  chemic  procedures  are  primarily  ap- 
plied for  the  purpose  of  removing  obstructions,  and  therapeutic 
applications  are  utilized  to  overcome  septic  conditions.  For  the 
latter  two  procedures  some  of  the  most  powerful  chemicals  and 
drugs  at  our  command  are  employed.  Callahan,  in  1893,  advo- 
cated the  use  of  50  per  cent  sulfuric  acid — other  investigators  sug- 
gested 10  per  cent  hydrochloric  or  even  pure  nitro-hydrochloric 
acid — for  the  enlargement  of  obliterated  root  canals,  and  Kirk,  in 
1894,  recommended  the  use  of  sodium  dioxid  in  conjunction  there- 
with. As  an  initial  step,  these  combined  procedures  constitute  the 
very  foundation  of  successful  root  canal  treatment  from  a  chemic 
point  of  view,  and  they  should,  as  a  matter  of  routine,  be  employed 
in  every  case.  Experimental  proof  of  the  soundness  of  this  con- 
ception and  long-extended  clinical  observations  substantiate  this 
claim. 

Soon  after  the  inauguration  of  the  antiseptic  era  in  surgery,  in 
1868,  by  Lister,  dentistry  adopted  his  methods  for  the  treatment 
of  root  canals  in  an  empirical  way  by  using  phenol  as  advocated  by 
Witzel,  in  1873.  Since  then  innumerable  drugs  and  drug  com- 
pounds have  been  recommended  at  various  times  for  this  purpose. 
From  a  clinical  point  of  view  the  cresol-formalin  mixture  as  in- 
troduced by  Gysi,  in  1899,  and  which  was  widely  popularized  by 
Buckley,  in  1904,  has  received  greater  approval  than  any  other 
medicinal  compound  recommended  for  such  purposes.  The  true 
criterion  of  the  efficiency  of  an  antiseptic  is  its  bacteriologic  test. 
The  high  standard  of  germicidal  activity  of  formalin  has  been  fre- 
quently established  by  rigorous  experiments.  Clinical  data  col- 
lected in  the  early  days  of  the  use  of  the  above  mixture  pointed  to 
most  favorable  results.  In  due  time,  however,  it  was  observed  that 
while  "clearing  up"  of  an  infected  root  canal,  as  far  as  the  ordi- 
nary diagnostic  evidence  is  concerned  as  applied  in  the  average 


486  PHYSICAL   THERAPEUTICS 

dental  office,  i.  e.,  absence  of  foul  odors,  occurred  much  more  rap- 
idly by  the  use  of  this  mixture  than  by  employing  any  of  the  nu- 
merous other  drugs  usually  advocated  for  this  purpose,  neverthe- 
less secondary  manifestations  about  the  periapical  tissues  were  of 
frequent  occurrence.  These  disturbances  are  an  indication  that 
the  supposed  sterility  of  the  canal  was  not  obtained  at  the  time  of 
its  treatment  with  the  cresol-formalin  mixture,  or  that  this  com- 
pound produces  a  predisposition  of  the  periapical  tissues  to  future 
infections.  To  be  sure,  dental  literature  is  pregnant  with  state- 
ments such  as  this  (referring  to  the  cresol-formalin  mixture)  : 
*  *  This  dressing  should  remain  for  at  least  three  days,  by  which  time 
the  remedy  will  have  sterilized  the  entire  tubular  structure  of  the 
dentin,  thus  establishing  asepsis."  As  no  bacteriologic  proof  is 
furnished  to  substantiate  the  claim,  this  empiric  statement  does  not 
carry  any  scientific  weight,  honest  as  its  intention  may  have  been. 

Much  stress  has  been  placed  in  the  past  on  the  nature  of  the 
root  canal  filling  material.  As  a  matter  of  fact,  the  discussion  of 
root  canal  treatment  in  current  literature  centers  almost  exclusively 
about  the  filling  of  the  canal,  and  less  so  about  the  means  of  obtain- 
ing its  sterility.  Artistic  root  canal  fillers  will  display  roent- 
genograms "before"  and  "after"  the  operation,  claiming  that  twiv, 
as  the  picture  shows,  a  perfect  root  canal  filling  obliterates  the  en- 
tire canal.  These  men  seemingly  forget  that  they  have  filled  only 
the  largest  tract  of  the  deltoid  branches  of  the  root  canal  within  the 
apical  region,  and  that  the  half  dozen,  more  or  less,  additional  rami- 
fications have  escaped  their  notice.  And  it  is  in  these  smaller  canals, 
unless  the  entire  region  is  definitely  sterilized,  that  bacteria  are  har- 
bored to  await  a  suitable  opportunity  for  propagation.  A  sterile 
root  canal  filling  acts  as  a  "mechanical"  antiseptic;  its  intention  is 
to  hermetically  seal  up  that  space  of  the  tooth  which  at  one  time  has 
been  occupied  by  the  pulp.  If  root  canal  fillings  were  a  perfect  re- 
plica of  the  former  pulp,  no  further  trouble  would  be  anticipated. 
The  numerous  recurrent  infections,  however,  tell  a  different  story. 

On  the  other  hand,  if  one  starts  out  with  a  sterile  root  canal 
and  can  furnish  proof  that  the  dentin  to  the  depth  of  one  or  two 
millimeters  is  sterile,  especially  so  within  the  apical  region,  which 
is  the  primary  seat  of  infection  and  of  reinfection,  the  root  canal 
fillings  placed  with  care  and  precision  will  furnish  a  greater  per- 


ELECTRO-STERILIZATION  487 

centage  of  "successes"  than  if  primarily  the  filling  is  begun  in  a 
root  canal  of  questionable  sterility.  Any  new  method,  therefore, 
which  promises  to  possess  superior  merits  over  existing  less  satis- 
factory procedures,  is  worthy  of  discussion.  The  writer  is  con- 
vinced that  the  process  of  electro-sterilization  of  infected  root  canals 
as  a  means  of  establishing  asepsis  is  an  advance  step  in  dental 
therapeutics,  and  is  deserving  of  earnest  consideration  by  the  clin- 
ical practitioner. 

History. — The  utilization  of  the  electric  current  for  the  purpose 
of  checking  bacterial  growth  is  by  no  means  of  recent  origin.  In  1883 
Cohn  and  Mendelsohn  employed  a  galvanic  current  experimentally 
to  study  its  effect  upon  bacteria  suspended  in  nutrient  solution. 
Apostoli  and  Laquerriere,  in  1890,  used  a  current  of  100  to  150  mil- 
liamperes  for  similar  purposes,  claiming,  however,  that  it  is  not  the 
current  as  such  but  the  electrolj^tic  decomposition  of  the  nutrient 
fluid  which  produces  the  desired  effects.  Similar  results  were  ob- 
tained by  Prochowink  and  Spaeth  in  the  same  year.  In  1891  Yer- 
soogen  claimed  that  the  bactericidal  effect  of  the  current  depended 
on  the  end  products  of  the  electrolytic  dissociation  of  a  suitable 
fluid,  i.  e.,  acid  at  the  positive  pole  and  alkali  at  the  negative  poje. 
The  application  of  this  principle  for  the  purpose  of  sterilizing  root 
canals  was  probably  first  attempted  by  Breuer  of  Vienna,  who,  as 
early  as  1890,  referred  to  this  method  in  a  tentative  manner.  In 
1895  Rhein,  at  the  suggestion  of  Morton,  employed  this  procedure 
in  an  empiric  way  with  apparent  good  success;  he,  again  demon- 
strated it  in  1897,  and  has  referred  to  it  at  various  times  ever  since. 
A  systematic  investigation  of  this  procedure  was  first  attempted  by 
Bethel  in  1896-97,  and  a  careful  perusal  of  his  publications  is  of  the 
highest  interest.  However,  it  remained  for  Zierler  to  furnish  a  de- 
tailed account  of  the  nature  of  the  action  of  the  galvanic  current  on 
bacterial  infection  of  root  canals,  and  his  work,  carried  out  in  con- 
junction with  Lehmann  at  the  University  of  Wiirzburg,in  1900,  must 
be  regarded  as  a  very  complete  expose  of  the  procedure.  Since  then 
quite  a  host  of  writers  have  elaborated  on  this  problem,  among  whom 
Hoffendahl,  Miller,  Peter,  J.  Forbes  Webster,  Frank  D.  Price,  Stur- 
ridge,  and  many  others  should  be  mentioned.  The  English-reading 
dental  profession  is  particularly  to  be  congratulated  on  the  excel- 
lent discussion  of  this  procedure  as  recorded  by  Sturridge  in  his 
commendable  work  "Dental  Electro-therapeutics," 


488  PHYSICAL   THERAPEUTICS 

The  term  ionization  as  applied  to  the  specific  purpose  of  electro- 
sterilization  of  root  canals  is  ill  chosen.  Ionization  designates 
purely  a  chemico-physical  process,  i.  e.,  by  the  phenomenon  of  elec- 
trolysis ions  are  induced  to  migrate.  Again,  the  term  ionic  medica- 
tion is  employed  for  such  procedures.  Lewis  Jones  defines  it  as 
follows :  ' '  Ionic  medication  is  a  method  of  treatment  in  which  elec- 
tric currents  are  used  for  their  power  of  setting  the  constituents  of 
a  saline  solution  in  orderly  motion  in  a  definite  direction.  It  is 
used  for  the  introduction  of  drugs  into  the  superficial  parts  of  the 
body  through  the  surface."  While  the  above  explanation  is  com- 
patible with  the  nature  of  ionic  medication  for  general  medicinal 
purpose,  it  does  not  specifically  designate  the  end  for  which  this 
procedure  is  applied  in  the  treatment  of  root  canals.  The  sole 
object  in  applying  this  treatment  consists  in  combating  infection  by 
the  most  powerful  method  known,  i.  e.,  sterilization.  The  latter  is 
induced  by  a  weak  electric  current  through  the  migration  of  certain 
ions.  Hence  the  term  sterilization  by  electrolysis,  or  in  short,  elec- 
tro-sterilization, as  first  suggested  by  Zierler,  is  eminently  suitable 
for  this  purpose,  and  its  general  adaptation  is  strongly  urged  by  the 
writer.  It  has  been  suggested  that  the  term  electro-sterilization 
merely  indicates  a  substitute  for  the  once  famous  therapeutic  pro- 
cedure known  as  cataphoresis.  This  conception  is  not  correct.  Cata- 
phoresis  designates  the  mechanical  movement  of  suspended  mole- 
cules by  means  of  the  electric  current.  As  such  it  is  a  process  inde- 
pendent of  electrolysis.  The  rationale  of  electro-sterilization  de- 
pends on  the  interaction  of  two  definite  processes:  (1)  the  disso- 
ciation of  a  suitable  chemic  compound  in  a  solvent  (electrolyte)  into 
ions,  and  (2)  the  movement  of  these  ions  in  the  direction  of  specific 
poles  within  the  tissues,  brought  about  by  the  passage  of  a  weak 
galvanic  current. 

Theory  of  Electrolytic  Dissociation. 

When  a  solid,  liquid,  or  gas  enters  into  solution  and  is  capable 
of  conducting  an  electric  current,  according  to  Arrhenius,  the  solu- 
tion undergoes  certain  changes  which  are  grouped  under  the  generic 
term  electrolysis.  This  latter  term  and  the  following  nomenclature 
was  introduced  by  the  English  physicist  Faraday  (1791-1867)  and 
is  still  universally  employed.     The  solution  itself  is  known  as  the 


ELECTRO-STERILIZATION 


489 


electrolyte,  while  the  dissociated  products  are  referred  to  as  ions. 
The  terminals  at  which  the  electric  current  enters  or  leaves  the  elec- 
trolyte are  called  electrodes.  An  ion  (ion  =  going)  may  be  referred 
to  as  being  the  dissociated  product  of  a  chemic  decomposition  which 
is  capable  of  conducting  an  electric  charge,  and  which  travels  in  the 
direction  of  an  oppositely  charged  pole.  Those  ions  which  are 
charged  negatively  migrate  to  the  anode,  i.  e.,  the  positive  pole,  and 
are  known  as  anions,  while  the  positively  charged  ions  migrate  to 
the  negative  pole, 'the  cathode,  and  are  known  as  cations.  Relatively 
speaking,  all  metals,  alkaloids  and  hydrogen,  are  positive  ions,  i.  e., 
cations,  while  all  acids,  bases,  halogens,  hydroxyl  compounds,  and 
oxygen  are  negative  ions,  i.  e.,  anions. 

TABLE  OF  IONS,  THEIR  ELECTRO-CHEMIC  EQUIVALENTS  AND  RELATIVE 
VELOCITIES  ACCORDING  TO  LEDUC. 


Ions 

Milligrams  per 
Coulomb 

Milligrams  per 

Milliampere- 

Minute 

Relative 
Velocities 

Anions: 

Bromin 

Chlorin 

0.82 

0.367 

0.18 

1.31 

1.4 

0.06 

0.206 

3.0 

0.678 

0.01 

0.07 

0.115 

1.03 

0.4 

3.9 

1.13 

1.1 

0.23 

3.4 

0.16 

0.33 

0.049 

0,022 

0.01 

0.078 

0.085 

0.003 

0.012 

0.18 

0.04 

0.0006 

0.004 

0.007 

0.062 

0.024 

0.234 

0.066 

0.06 

0.014 

0.207 

0.01 

0.02 

0.9 
1.0 

Hydroxyl 

1.27 

lodin 

1.16 

Salicylic  Acid 

Cations: 

Ammonium 

1.56 

Calcium 

0.5 

Cocain 

0.59 

Gold 

1.22 

Hydrogen 

0.88 

Lithium 

1.28 

Magnesium 

0.5 

Mercury 

0.8 

Potassium 

1.0 

Quinin 

0.62 

Radium 

Silver 

6.5 

Sodium 

1.6 

Strychnin 

Sulphur 

Zinc 

6.6 

As  Ostwald  has  suggested,  the  cation  may  be  designated  by  the 
positive  sign  +  or  by  •,  and  the  anion  by  the  negative  sign  —  or 
by  '.  "An  ion  may  be  either  a  charged  atom,  as  in  the  case  of  the 
silver  ion,  or  a  charged  group  of  atoms,  or  molecules.  In  the  case 
of  silver  nitrate,  Ag  NO3,  the  cation  is  Ag,  and  the  anion  is  the  mole- 


490 


PHYSICAL    THERAPEUTICS 


cule  or  radicle  NO3.  The  charge  of  the  NO3  ion  is  one  negative  unit, 
and  that  of  the  Ag  ion  is  one  positive  unit,  as  both  the  ions  are 
monads,  or  monatomic."     (Lewis  Jones.) 

A  simple  solution  of  salt  in  water  dissociates  the  salt  into  electro- 
molecules,  the  ions,  which  exist  independently  of  the  action  of  a  gal- 
vanic current.  The  number  of  positively  and  negatively  charged 
ions  is  equi-molecular,  i.  e.,  the  solution  is  electrically  neutral.  The 
ions  themselves  are  suspended  in  the  solution  in  a  chaotic  mixture. 
The  passing  of  the  galvanic  current,  according  to  Nernst,  by  its 
electro-motive  force  causes  a  definite  movement  of  the  ions  in  an  or- 

C 
|i 


-H 


:::::®:::::^G 


.__©.-^._JL(i>.^. 


Fig.   102. 
Scheme  showing  the  movement  of  ions. 

derly  direction  to  their  specific  centers  of  attraction;  i.  e.,  respec- 
tively to  the  positive  and  the  negative  pole. 

The  nature  of  the  movement  of  ions  may  be  theoretically  ex- 
plained, according  to  Nernst,  by  the  following  schematic  drawing 
(Fig.  102). 

According  to  the  above  scheme,  if  two  zinc  electrodes  are  charged, 
A  and  B,  suspended  in  a  zinc  chlorid  solution,  D,  from  a  battery  C, 
the  positive  zinc  ions,  F,  are  attracted  to  the  negatively  charged 
electrode,  B,  and  slowly  they  move  in  the  direction  of  this  pole. 


ELECTRO-STERILIZATION  491 

The  zinc  ions  discharge  their  positive  charge,  thereby  releasing  the 
negatively  charged  electrode.  The  discharged  zinc  ions  are  now 
formed  into  ordinary  metallic  zinc.  The  positively  charged  elec- 
trode, A,  attracts  the  negatively  charged  chlorin  ions,  E ;  the  latter 
discharge  themselves  and  dissolve  metallic  zinc,  forming  zinc  chlorid, 
which  at  once  is  again  ionized.  The  resultant  ions — zinc  and  chlorin 
— are  dispersed  in  the  solution.  Undissociated  molecules,  G,  of  zinc 
chlorid  present  in  the  solution  are  not  acted  upon  by  the  current. 
The  movement  of  these  ions  occurs  comparatively  slowly  and  may 
be  accurately  measured  by  means  of  an  ingenious  apparatus  devised 
by  Kohlrausch. 

Experiment:  Ionization. —  (1)  Moisten  a  piece  of  starch-iodid 
paper  with  water.  Apply  the  two  poles  about  one  inch  apart.  A 
blue  spot  will  develop  under  the  positive  pole.  The  iodid  salt  is 
ionized,  and  the  liberated  iodin  colors  the  starch  blue. 

(2)  Moisten  a  piece  of  cotton  with  a  weak  solution  of  potassium 
ferricyanid.  The  positive  pole  of  the  battery  consists  of  a  piece  of 
clean  iron  wire.  After  the  battery  is  turned  on  an  intense  blue 
color,  Prussian  blue,  i.  e.,  iron  ferrocyanid,  appears  at  the  positive 
pole. 

The  degree  of  concentration  of  the  solution  to  be  ionized  has  no 
effect  upon  the  number  of  ions  produced ;  the  latter  depends  upon 
the  strength  of  the  current  multiplied  by  the  time  for  which  it  is 
applied.  In  other  words,  ionization  is  a  manifestation  of  trans- 
formed electric  energy  in  accordance  with  Faraday's  law.  The 
amount  of  decomposition  of  an  electrolyte  is  proportional  to  the 
amount  of  electricity  which  flows  through  it. 

The  process  of  electro-sterilization  of  infected  root  canals  con- 
cerns itself  primarily  with  the  disinfectant  action  of  the  liberated 
ions,  and  less  so  with  their  supposed  medicinal  qualities.  The  dis- 
infectant action  is  principally  confined  to  the  surface  of  the  object 
treated  although  a  certain  depth  of  penetration  is  desirable.  Ac- 
cording to  Sir  Oliver  Lodge,  chlorin  the  principal  agent  depended 
upon  in  root  sterilization  develops  a  velocity  of  penetration  amount- 
ing to  2.16  mm.  per  hour  for  a  drop  of  potential  of  1  volt  per  cm. 

Experiment:  Movement  of  Ions. — (1)  A  saturated  solution  of 
copper  sulphate  is  placed  in  a  small  beaker  to  the  depth  of  one  inch. 
An  insulated  piece  of  copper  wire  having  one-half  inch  exposed  at 
each  end  is  placed  into  the  solution  and  united  to  the  negative 


492 


PHYSICAL    THERAPEUTICS 


pole.  A  similar  piece  is  hung  over  this  solution  and  united  to  the 
positive  pole.  A  one-half  per  cent  sodium  chlorid  solution  is  care- 
fully flowed  over  the  copper  solution  by  means  of  a  pipet.  The  cur- 
rent is  turned  on,  and  slowly  the  blue  cupric  ions  are  seen  moving 
into  the  colorless  sodium  chlorid  solution. 

(2)  A  glass  tube,  three  inches 
long  and  one-half  inch  in  diameter, 
is  filled  with  an  alkaline  10  per  cent 
gelatin  solution  containing  1  per 
cent  of  sodium  chlorid  and  colored 
pink  with  phenolphthalein.  Insert 
a  cork  carrying  a  platinum  wire  at 
each  end,  and  unite  the  wires  to  the 
two  poles.  In  due  time  the  pinli 
color  will  disappear  near  the  posi- 
tive electrode,  indicating  the  move- 
ment of  the  chlorin  (hydrochloric 
acid)  ions. 

(3)  Repeat  the  above  experi- 
ment, but  substitute  for  the  wire  of 
the  one  cork  a  tooth  having  a  gan- 
grenous pulp  (Fig.  103).  The 
debris  of  the  pulp  is  removed,  and 
the  broach  passed  through  the  fora- 
men. The  canal  is  filled  with  salt 
water  and  the  iridio-platinum  elec- 
trode— positive  pole — is  inserted 
into  the  root  canal,  passing  slightly 

1  beyond  the  foramen.    Apply  a  cur- 

1 1  rent  of  5  milliamperes  for  six  min- 

-^  utes.     Notice   the   discolored  zone 

^  near   the    foramen    of    the    tooth, 

which  becomes  more  definitely  out- 
lined within  the  next  twenty-four 
hours.  Remove  the  tooth  and  split 
it  open.  Notice  the  odor  of  chlorin 
and  the  bleaching  effect  on  the  surface  of  the  root  canal. 

(4)  Place  a  positive  pole  of  zinc  and  a  negative  pole  of  copper 
into  a  weak  solution  of  zinc  chlorid.     Within  a  few  minutes  the 


Fig.   103. 
Experiment  showing  passage  of  ions. 


ELECTRO-STERILIZATION  493 

negative  copper  pole  will  be  coated  over  (plated)  with  metallic  zinc. 

The  electric  current  per  se,  i.  e.,  at  least  in  the  strength  suitable 
for  root  sterilization,  does  not  produce  any  measurable  bactericidal 
action,  A  weak  current  passed  for  hours  through  diluted  sulphuric 
acid  prior  to  entering  an  inoculated  Petri  dish  did  not  inhibit  the 
growth  (Lehmann).  In  the  presence  of  an  electrolyte,  the  current 
acts  on  the  dissociated  ions  of  the  latter,  and,  depending  upon  their 
specific  chemic  nature,  some  of  the  most  powerful  disinfectants  may 
be  obtained.  It  is  claimed  that  certain  pure  metals  as  such  possess 
slight  antiseptic  action.  This  property  was  first  observed  by  the 
late  Professor  Miller.  According  to  Behring,  this  antiseptic  action 
is  the  result  of  the  reaction  of  certain  waste  products  of  bacteria, 
primarily  lactic  acid,  with  those  metals  which  are  capable  of  form- 
ing soluble  salts,  and  which  diffuse  through  the  medium.  This 
antiseptic  action  of  metals  must  not  be  confounded  with  the  oligo- 
dynamic action  of  certain  pure  metals  in  their  colloidal  state,  as 
copper,  for  instance,  on  low-type  plant  cells.  Of  the  pure  metals, 
according  to  the  classic  experiments  made  by  Thiele  and  Wolf, 
mercury,  silver,  and  copper  are  the  only  ones  which  produce  poi- 
sonous salts  in  the  presence  of  bacteria,  while  the  other  tested  metals, 
i.  e.,  platinum,  palladium,  gold,  aluminum,  magnesium,  zinc,  lead, 
tin,  and  iron  are  wholly  devoid  of  action.  In  the  discussion  of 
electro-sterilization  of  infected  root  canals,  great  stress  is  fre- 
quently laid  by  certain  men  upon  the  specific  nature  of  the  metallic 
electrode  placed  in  the  root  canal  as  being  the  factor  which  pro- 
duces the  desired  germicidal  effect.  Rhein,  for  instance,  insists  on 
using  a  chemically  pure  zinc  electrode  in  the  presence  of  a  sodium 
chlorid  solution,  claiming  that  "nascent  zinc  chlorid"  is  formed 
during  the  process  of  electrolysis.  Other  practitioners  employ  a 
copper  electrode  and  a  weak  zinc  chlorid  solution  as  a  substitute  for 
the  sodium  chlorid  solution.  A  zinc  electrode  employed  for  electro- 
sterilization  of  root  canals  is  not  only  devoid  of  any  germicidal 
action,  but  it  is  also  an  ill-chosen  metal  for  this  purpose,  because  a 
zinc  wire  is  too  brittle  to  be  filed  fine  enough  so  as  to  readily  enter 
a  minute  root  canal  without  inviting  danger  of  breaking. 

Ionization  of  a  metallic  electrode  occurs  primarily  in  the  presence 
of  a  suitable  electrolyte,  i.  e.,  a  solution  of  a  salt  of  the  metal  of 
the  respective  electrode.  While  theoretically  it  is  true  that  ions  of 
the  respective  electrode  must  be  produced  as  a  secondary  sequence 


494  PHYSICAL   THERAPEUTICS 

of  the  primary  ionization  of  the  electrolyte,  practically,  in  em- 
ploying the  low  amperage  tolerated  by  the  human  body  these  ions 
are  not  demonstrable  with  the  ordinary  chemic  reactions,  conse- 
quently they  can  not  exercise  any  therapeutic  effect.  A  zinc  elec- 
trode in  the  presence  of  a  sodium  chlorid  solution  is  not  ionized 
in  the  short  space  of  time  and  with  the  low  amperage  employed 
in  the  electro-sterilization  of  root  canals,  consequently  "nascent 
zinc  chlorid"  ions,  which  Rhein  believes  to  have  been  produced 
from  his  zinc  electrodes,  are  imaginary  therapeutic  bodies ;  such  ions 
do  not  exist.  When  a  high  amperage  is  employed — in  experimental 
work  outside  of  the  human  body — sufficient  hydrochloric  acid  is  ob- 
tained as  a  secondary  product  which  will  act  on  the  zinc  pole,  form- 
ing zinc  chlorid.* 

Experiments. —  (a)  To  show  the  nonexistence  of  zinc  ions  in  the 
presence  of  a  sodium  chlorid  electrolyte. 

(1)  The  positive  zinc  electrode  and  a  negative  copper  electrode 
are  placed  about  an  inch  apart  in  a  dish  filled  with  a  1  per  cent 
sodium  chlorid  solution.  A  current  of  5  milliamperes  is  passed 
through  the  solution  for  6  minutes.  The  addition  of  ammonium  sul- 
phid  does  not  reveal  the  presence  of  zinc  in  solution.  By  adding  one 
drop  of  a  weak  zinc  chlorid  solution,  the  presence  of  metallic  zinc  is 
at  once  manifested. 

(2)  Repeat  the  same  experiment  as  above,  but  substitute  the  zinc 
electrode  by  a  silver  electrode.  No  precipitation  of  silver  chlorid 
occurs,  consequently  no  silver  ions  are  formed. 

(b)  To  show  the  existence  of  zinc  ions  in  the  presence  of  a  zinc 
chlorid  electrolyte. 

The  positive  zinc  and  the  negative  copper  electrodes  are  placed  in 
a  dish  filled  with  a  1  per  cent  zinc  chlorid  solution,  and  the  current 
is  applied  as  above.  In  a  few  minutes  the  copper  electrode  is  com- 
pletely covered  by  a  coating  of  zinc,  i.  e.,  it  is  "zinc-plated."  If  the 
zinc  electrode  is  carefully  weighed  before  and  after  the  experiment, 
a  ponderable  difference  of  this  zinc  electrode  is  demonstrable. 

To  cite  the  often  repeated  experiment  of  placing  copper  electrodes 
into  a  hard-boiled  egg  and  then  passing  a  current  through  it  and 
thus  producing  green-colored  copper  compounds  near  the  positive 


•During  the  past  year  the  writer  has  experiinehted  with  organic  and  inorganic  metal 
salts  in  connection  with  electro-sterilization.  The  results  of  these  experiments  are  as  yet 
too  incomplete  to  allow  specific  deductions  to  be  drawn  therefrom;  nevertheless  they  point 
in  a  direction  which  strongly  encourages  their  further  pursuit. 


ELECTRO-STERILIZATION  495 

pole  as  a  proof  of  the  ionization  of  copper,  is  by  no  means  a  coun- 
terproof  of  what  has  been  stated  above,  but  rather  supports  the 
author's  contention.  The  coagulated  albumen,  of  course,  does  not 
represent  albumin  as  present  in  the  tissues.  If  a  comparison  is  to 
be  drawn  from  this  experiment,  fresh  egg  albumen  should  be  used 
instead.  By  passing  a  current  through  it,  it  will  be  seen  that  green- 
colored  copper  compounds  are  formed  about  the  positive  pole,  and 
coagulation  (by  heat)  occurs  near  the  negative  pole.  Albumen  is  a 
highly  complicated  amphoteric  electrolyte,  i.  e.,  it  represents  multi- 
basic  acids  and  multi-acid  bases,  hence  the  reaction.  This  holds 
equally  good  for  gelatin  solutions,  although  they  are  more  pro- 
nouncedly acid  in  reaction. 

Copper  or  silver  wires  may  be  used  as  positive  poles  in  electro- 
sterilization.  They  are  inferior,  however,  to  iridio-platinum,  because 
in  the  presence  of  suitable  electrolytes  they  are  ionized,  i.  e.,  de- 
stroyed, and  incidentally  they  discolor  tooth  structure.  Pure  plati- 
num is  not  measurably  altered  by  the  process  of  electrolysis,  but  it 
is  too  soft  for  our  purpose.  An  alloy  of  iridio-platinum  possesses 
the  ideal  qualifications  regarding  adaptability  and  durability  as  a 
root  canal  electrode,  and  it  is  therefore  strongly  recommended  by 
the  writer  as  the  most  suitable  metal  for  the  purpose  in  view. 

The  variability  of  resistance  of  the  human  body  to  the  passing  cur- 
rent naturally  materially  influences  its  therapeutic  effects.  Taking 
into  consideration  the  distance  between  the  two  poles,  the  respective 
biologic  nature  of  the  tissues,  and  other  factors,  it  may  be  stated 
that,  in  round  figures,  the  human  body  offers  a  resistance  which 
equals  from  5000  to  100,000  ohms.  In  a  pulpless  tooth  the  root 
canal  of  which  is  filled  with  salt  water  for  the  purpose  of  electro- 
sterilization,  the  resistance  is  low,  i.  e.,  only  a  few  volts  are  required ; 
while  if  a  tooth  is  previously  deprived  of  its  natural  moisture  or  if 
its  foramina  are  closed,  an  enormously  high  voltage,  i.  e.,  up  to  the 
full  capacity  of  the  current,  is  required  to  force  its  passage  laterally 
through  the  dentin. 

(c)  To  show  the  depth  of  the  penetration  of  ions  into  the  dentin 
in  a  tooth  with  a  closed  foramen. 

A  tooth  whose  foramen  is  tightly  closed  by  gutta-percha,  and  the 
apex  of  which  is  dipped  into  melted  paraffin,  is  filled  with  silver 
nitrate  solution ;  the  positive  electrode  consists  of  a  piece  of  pure 
silver  wire.    The  tooth  is  suspended  in  a  sodium  chlorid  solution  up 


496  PHYSICAL   THERAPEUTICS 

to  within  a  quarter  of  an  inch  of  its  gingival  margin.  Usually,  the 
full  voltage  of  the  current  is  required  to  register  one  milliampere  of 
flow.  Slowly  the  amperage  increases  to  about  4  milliamperes.  After 
about  ten  minutes  the  current  is  turned  off,  the  tooth  is  removed, 
washed,  and  sections  are  cut.  Under  the  microscope,  the  penetration 
of  the  silver  nitrate  can  be  observed  only  to  the  depth  of  a  few 
millimeters.  No  precipitation  of  silver  chlorid  takes  place  in  the 
salt  water.  The  same  experiment  repeated  with  an  iron  electrode  in 
the  presence  of  a  potassium  ferricyanid  solution  showed  only  the 
very  faintest  trace  of  Prussian  blue  upon  the  inner  wall  of  the 
canal. 

A  most  naive  explanation — ' '  to  show  the  antiseptic  or  germicidal 
properties  of  zinc  ions ' ' — is  furnished  in  a  recent  paper  by  J.  Forbes 
Webster.    He  says : 

* '  To  show  the  antiseptic  or  germicidal  properties  of  zinc  ions,  three  U  tubes, 
a,  6,  c,  were  taken,  and  a  small  quantity  of  ordinary  broth  medium  (which 
contains  meat  extract,  peptone,  and  NaCl)  was  introduced  into  each.  Each 
tube  of  broth  was  lettered  and  then  inoculated  with  some  saliva,  o  was  kept 
as  a  control,  b  was  connected  with  a  battery,  the  anode  or  positive  pole  being 
a  small  piece  of  pure  zinc.  A  current  of  15  to  20  m.a.  was  passed  for  25  min- 
utes, c  was  used  as  a  control  to  &,  being  connected  to  the  battery  in  the  same 
way,  but  no  current  passed.  The  three  tubes  were  then  put  in  the  incubator 
for  twenty-four  hours,  a  and  c  showed  abundant  growth,  but  no  growth  was 
visible  in  6,  nor  could  sub-cultures  be  obtained  from  6.  This  goes  to  prove  that 
the  zinc  ions  had  sterilized  the  broth." 

Webster 's  deductions  are  based  upon  insufificient  chemical  knowl- 
edge. Aside  from  the  statement,  "This  goes  to  prove  that  the  zinc 
ions  had  sterilized  the  broth, ' '  no  real  proof  is  furnished  to  substan- 
tiate his  claim.  The  true  nature  of  the  sterilization  as  demonstrated 
by  this  experiment  is  found  in  the  fact  that  the  current  has  ionized 
the  sodium  chlorid  present  in  the  broth.  If  Webster  had  substituted 
a  platinum  wire,  which  is  not  ionized,  for  his  zinc  electrode,  he  would 
have  been  surprised  to  obtain  identically  the  same  results. 

Webster  cites  a  second  experiment:  "To  show  that  the  zinc  ions 
pass  through  the  tissues,  I  devised  an  experiment  by  passing  the 
ions  through  coagulated  albumen."  He  describes  in  detail  the  ap- 
paratus employed,  stating  that — "The  negative  electrode  consisted 
of  a  platinum  wire  leading  to  a  pledget  of  cotton  wool  moistened 
with  a  normal  saline  solution.  The  zinc  electrode  was  then  care- 
fully brought  in  contact  with  the  coagulated  albumen,"  etc.     He 


ELECTRO-STERILIZATION  497 

claims  that  "No  growth  was  obtained,  which  goes  to  prove  that  the 
zinc  ions  had  passed  through  the  coagulated  albumen  and  sterilized 
the  broth."  If  Webster  had  left  out  of  this  experiment  "a  pledget 
of  cotton  wool  moistened  with  normal  saline  solution,"  his  "zinc 
ions"  would  have  never  sterilized  his  broth. 

The  Electric  Current  and  Its  Accessories. 

The  only  current  suitable  for  electro-sterilization  is  the  direct  cur- 
rent. The  alternating  current  as  such  can  not  be  used  unless  it  is 
changed  by  a  transformer.  This  may  be  accomplished  by  a  chemic 
"rectifier"  or  a  small  motor  dynamo.  The  chemic  rectifier  without 
potential  equalizer  has  not  been  found  satisfactory  by  the  writer. 
The  source  of  the  current  may  be  obtained  from  the  main  line,  from 
an  accumulator  or  a  storage  battery,  or  from  a  series  of  cells.  If  the 
street  current  is  used,  it  must  be  reduced  by  a  rheostat  to  about  30 
to  40  volts.  A  number  of  lamps,  mounted  in  series,  one  lamp  of  suf- 
ficiently high  voltage,  or  a  wire  rheostat,  is  usually  employed  for 
this  purpose.  An  ordinary  switchboard  is  less  suitable,  as  there  is 
always  danger  of  shocking  the  patient  through  imperfect  control. 
If  the  street  current  is  used  a  knife  switch  should  be  interposed  be- 
tween the  rheostat  and  the  current  controller.  If  cells  are  employed 
— and  many  practitioners  and  most  of  the  reliable  electric  supply 
houses  regard  a  cell  series  as  the  safest  means  for  the  purpose  in 
view — about  18-24  Leclanche  wet  cells  or  an  equal  number  of  ordi- 
nary dry  cells  (Columbia  No.  6)  are  most  useful.  The  silver  chlorid 
cell  is  less  serviceable  for  our  purpose.  An  ordinary  wet  or  dry  cell 
furnishes  approximately  a  little  over  one  and  one-half  volts.  Re- 
cently, compact  types  of  dry-cell  batteries  furnishing  a  current  of 
very  low  amperage  and  medium  voltage,  intended  for  wireless  teleg- 
raphy, have  been  placed  on  the  market.  These  cells  are  also  useful 
for  dental  electro-sterilization.  The  cells  are  mounted  in  series,  and 
connected  to  binding-posts.  From  these  posts  the  current  is  con- 
veyed by  means  of  flexible  conducting  cords  of  specific  colors  to  a 
suitable  controller.  The  most  important  feature  of  a  serviceable 
controller  consists  in  the  gradual  increase  or  decrease  of  the  current 
in  very  small  fractions  of  a  milliampcre  without  shocking  the  patient. 
A  graphite  or  a  series  wire  rheostat,  either  plain  or  as  a  shunt,  is 
serviceable  for  such  purposes.    The  markings  on  the  current  con- 


498 


PHYSICAL    THERAPEUTICS 


troller  (Fig.  104),  be  they  volts  or  arbitrary  numbers,  have  little 
bearing  on  the  practical  application  of  the  current. 

The  current  controller,  in  turn,  is  connected  with  a  milliampere- 
meter,  an  instrument  for  measuring  the  quantity  or  strength  of  the 
current.    The  milliamperemeter  is  the  instrument  of  precision  which 


Fig.   104. 
The  S.   S.  White  current  controller. 


Fig.   105. 
Weston  milliamperemeter. 

guides  the  operator  in  his  work,  consequently  too  much  emphasis 
can  not  be  placed  upon  the  importance  of  obtaining  a  perfect  work- 
ing instrument. 

At  this  point  the  writer  may  be  permitted  to  digress  for  a  moment 


ELECTRO-STERILIZATION 


499 


Fig.   106. 
Metal  negative   hand  electrode. 


500  PHYSICAL   THERAPEUTICS 

from  the  subject  proper  and  call  to  the  mind  of  the  reader  the  fun- 
damental nomenclature  governing  electrical  measurements — as  far 
as  it  is  utilized  in  the  following  discussion.  By  the  term  ampere  is 
meant  the  unit  of  strength  of  a  current.  A  milliampere  is  a  thou- 
sandth part  of  an  ampere,  expressed  as  m.a  A  volt  is  the  measure 
of  the  unit  of  pressure  of  the  current,  i.  e.,  the  electric  power  neces- 
sary to  drive  a  current  of  one  ampere  through  a  resistance  of  one 


Fig.   107. 
Sponge  negative  hand  electrode. 


Fig.   108. 
Sponge  wrist  electrode. 

ohm.  It  is  referred  to  as  the  electro-motive  force  and  expressed  as 
E.M.F.  An  ohm  measures  the  resistance  of  a  circuit  through  which  a 
current  flows. 

From  the  above  explanation  as  related  to  the  process  of  electro- 
sterilization,  it  is  obvious  that  the  correct  measurement   of  the 


ELECTRO-STERILIZATIOr>r  501 

amount  of  current  applied  to  a  patient  is  of  the  utmost  importance, 
as  it  is  the  safest  means  of  guiding  us  during  its  application.  Hence 
the  importance  of  procuring  a  trustworthy  milliamperemeter.  The 
best  instruments  are  those  constructed  after  the  Deprez-d 'Arsonval 
deadbeat  (nontrembling)  type.  The  Weston  milliamperemeter 
(Fig.  105)  is  a  most  reliable  current  gauge.  The  face  of  the  latter 
instrument,  suitable  for  this  work,  should  be  calibrated  into  five  mil- 
liamperes,  with  subdivisions  of  a  tenth  to  a  twentieth  of  a  milli- 
ampere.  To  convey  the  current  to  the  patient,  different  colored  flex- 
ible cords  are  employed  which  terminate  in  suitable  electrodes.    In 


Fig.   109. 
Long-handle  electrode  with  iridio-platinum   point. 

connecting  up  the  whole  apparatus  extreme  care  must  be  observed 
in  joining  equal  poles  to  each  other ;  viz.,  positive  pole  must  be  con- 
nected to  positive  pole,  and  vice  versa.  To  locate  the  respective 
poles,  the  following  simple  experiment  may  be  employed. 

Experiment:  Location  of  PoLES.^Moisten  a  piece  of  blue  lit- 
mus paper  with  water.  Place  the  two  poles  of  the  battery  about  one 
inch  apart  on  the  wet  paper  and  turn  on  the  current.  In  a  few  mo- 
ments a  pink  spot  will  develop  where  the  positive  pole  touches  the 
paper. 


^SS^ 


Fig.   110. 
Insulated  electrode  holder. 

The  two  electrodes  are  terminals  attached  for  the  purpose  of  con- 
veying the  current  to  the  patient,  and  consist  of  a  negative  electrode 
which  is  to  be  placed  on  the  patient's  skin  surface,  and  a  positive 
electrode  to  be  introduced  into  the  tooth.  The  negative  electrode 
may  be  a  piece  of  metallic  tubing  held  firmly  in  the  patient's  hand, 
or  a  sponge  electrode  fastened  to  his  wrist,  or  one  of  various  modifi- 
cations thereof.  The  size  of  the  negative  hand  electrode  is  import- 
ant ;  it  should  present  at  least  five  square  inches  surface  area,  which 
are  to  be  brought  into  contact  with  the  patient.    A  large  surface  of 


502 


PHYSICAL   THERAPEUTICS 


the  negative  electrode  reduces  the  resistance,  and  consequently  the 
tingling  sensation  or  even  blistering  caused  by  the  heat  of  a  small 
electrode  is  avoided.  The  writer  prefers  the  plain  tube  hand  elec- 
trode, as  it  avoids  the  cumbersome  wetting  with  salt  water,  loss 
of  time  in  adjusting  it,  etc.  It  is  immaterial  in  which  hand  the  elec- 
trode is  held.  Rings,  bracelets,  wrist-watches,  etc.,  must  be  removed, 
otherwise  blistering  of  the  patient's  skin  by  mere  contact  may  oc- 


Fig.   111. 
Galvanic   battery   for  electro-sterilization. 

cur.  To  place  the  negative  electrode  upon  the  patient's  cheek,  lip, 
or  gum  surface  by  means  of  a  clamp  or  spring,  as  recommended  by 
some  operators,  is  to  be  avoided,  for  the  reason  that  severe  burns 
may  result.  It  has  been  stated  that  this  blistering  results  from  the 
formation  of  caustic  sodium  hydroxid  near  the  negative  pole.  The 
blistering  is  the  result  of  imperfect  contact  between  the  skin  and 


ELECTRO-STERILIZATION  503 

the  metal  electrode,  thereby  increasing  the  resistance  of  a  small  area 
to  such  an  extent  as  to  produce  high  heat,  i.  e.,  an  electric  burn. 
The  positive  electrode  to  be  introduced  into  the  tooth  consists  of 
a  piece  of  iridio-platinum  wire  No.  20  gauge,  about  one  inch  long  and 
tapered  to  a  delicate  point.  The  iridio-platinum  alloy  possesses  the 
necessary  flexibility,  which  is  lacking  in  pure  platinum.  The  point 
itself  is  ground  blunt  so  as  to  avoid  being  caught  when  introduced 


Fig.  112. 
Switchboard  for  electro-sterilization.      (Mcintosh.) 

into  tortuous  canals.  Various  sizes  of  these  points  may  be  kept  on 
hand.  No  other  metal  should  be  employed  for  such  purposes.  To 
substitute  the  iridio-platinum  point  by  zinc,  copper,  or  any  other 
metal  with  the  view  of  aiding  its  therapeutic  effects  is  not  only  use- 
less but  it  markedly  interferes  with  the  action  of  electrolysis  in  the 
relatively  small  area  of  a  root  canal,  or  the  resultant  ions  may  dis- 


504 


PHYSICAL   THERAPEUTICS 


color  the  tooth.  A  long-handle  electrode  holder,  insulated  with  hard 
rubber,  is  essential  to  suitably  unite  the  electrode  with  the  conduct- 
ing cord.  The  holders  may  be  of  various  types  so  as  to  give  ready 
access  to  all  parts  of  the  oral  cavity.  From  the  foregoing  description 
of  the  source  of  the  current,  its  control,  and  its  mode  of  application, 
it  may  be  observed  that  essentially  it  is  a  duplicate  of  the  armamen- 
tarium as  applied  in  producing  cataphoresis.    Any  apparatus,  there- 


Fig.  113. 

Switchboard   for   electro-sterilization. 

fore,  that  is  or  has  been  used  for  inducing  cataphoresis  may  be 
equally  successfully  employed  for  the  electro-sterilization  of  root 
canals. 

Chlorin  as  a  Disinfectant. 

Of  all  the  known  cheniic  disinfectants,  chlorin,  freshly  prepared, 
and  in  the  presence  of  moisture  and  a  suitable  temperature,  possesses 
the  greatest  known  germicidal  power.  Chlorin  forms  the  active 
constituent  of  Labarraque's  solution,  Javelle  water,   antiformin, 


ELECTRO-STERILIZATION  505 

otherwise  known  as  dental  radicin,  electrozone,  or  dental  meditrina, 
and  of  the  antiseptic  solution  so  successfully  employed  at  present  in 
the  English  and  French  war  hospitals  according  to  Dakin's  formula 
by  the  Carrel  method,  which  latter  preparation  is  now  advertised 
abroad  as  eusol,  and  in  our  country  in  the  form  of  a  salt,  as  chlora- 
zene.  The  great  success  obtained  with  Dakin's  solution  rests  pri- 
marily upon  the  fact  that  a  fresh  preparation  according  to  a  specific 
(Carrel)  method  is  employed,  which,  while  acting  deleteriously  on 
the  germs,  does  little  harm  to  the  tissue  cells,  as  it  is  a  nonirritating 
isotonic  wound  antiseptic.  All  of  these  solutions  have  sporadically 
come  to  prominence  in  the  past.  While  the  laboratory  reports,  as 
far  as  the  germicidal  power  of  these  solutions  is  concerned,  appear 
to  be  highly  satisfactory,  practical  application  does  not  bear  out 
the  enthusiasm.  It  should  be  borne  in  mind  that  most  of  these 
preparations  are  irritating,  and  that  chlorin  solutions  are  labile 
compounds.  All  of  these  enumerated  solutions  lose  their  activity 
within  a  week  or  two,  hence  the  disappointing  results  when  com- 
mercial stock  preparations  are  employed. 

The  rationale  of  sterilizing  an  infected  wound  surface  by  the 
Carrel  method  is  based  on  the  following  conception:  ''To  render 
an  infected  wound  sterile  it  is  necessary  to  employ  a  suitable  anti- 
septic in  such  a  manner  that  the  chosen  antiseptic  comes  into  con- 
tact with  every  portion  of  the  wound,  that  the  antiseptic  is  main- 
tained in  a  suitable  concentration  throughout  the  entire  wound, 
and  that  this  constant  strength  is  maintained  for  a  prolonged 
period.  If  these  conditions  are  fulfilled,  every  wound  will  show  its 
response  to  the  treatment  by  the  diminution  and  disappearance  of 
its  micro-organisms."  To  the  ionization  of  a  1  per  cent  sodium 
chlorid  solution  by  means  of  the  galvanic  current  within  a  root 
canal  furnishes  free  chlorin  in  statu  nascendi  in  the  presence  of 
moisture  and  body  temperature  which  is  most  active,  and  admir- 
ably suited  for  our  purposes.  The  free  chlorin  sterilizes  the  walls 
of  the  root  canal  (see  below)  and  bleaches  the  discolored  dentin. 
Incidentally,  the  ionization  of  the  salt  water  furnishes  an  appre- 
ciable amount  of  hydrochloric  acid  which  acts  as  a  superficial  sol- 
vent of  tooth  structure,  and  thereby  enlarges  the  root  canal.  The 
two  chemicals,  according  to  Lehmann-Zierler,  are  present  in  the 
proportion  of  five  parts  chlorin  to  three  parts  of  hydrochloric  acid. 
The  small  quantities  of  sodium  compound  which  are  formed  within 


506  PHYSICAL   THERAPEUTICS 

the  vicinity  of  the  negative  pole  are  taken  care  of  by  the  tissue 
fluids. 

Experiment:  Presence  of  Chlorin. — Place  the  two  poles  upon 
a  piece  of  filter  paper  moistened  with  a  solution  of  indigo  blue  in 
sodium  chlorid  solution.  Within  a  few  minutes  the  blue  color  Avill 
disappear,  due  to  the  reducing  (bleaching)  effect  of  the  liberated 
chlorin.    Notice  the  odor  of  chlorin. 

Much  importance  has  been  attributed  by  some  writers  to  the 
presence  of  ozone  and  nascent  oxygen  formed  during  the 
decomposition  of  sodium  chlorid  according  to  the  equa- 
tion :  H2O  +  CI2  =  2HC1  +  0.  The  presence  of  ozone  could  not 
be  detected  chemically.  The  small  quantity  of  free  oxygen  may  be 
considered  a  negligible  factor  as  far  as  disinfectant  action  in  this 
connection  is  concerned.  Silver  salt  solutions,  as  has  been  definitely 
demonstrated  by  Bethel,  or  copper  or  mercury  salt  solutions,  may 
be  used  for  the  purpose  of  sterilizing  root  canals  in  connection  with 
the  electric  current.  While  these  solutions,  if  one  depends  upon 
their  metallic  ions,  are  proportionately  weaker  than  the  chlorin 
ion  obtained  from  a  sodium  chlorid  solution,  incidentally  they  al- 
ways discolor  the  tooth  structure,  and  consequently'  offer  no  ad- 
vantage. Zinc  chlorid  solution,  which  seems  to  be  largely  em- 
ployed for  such  purposes,  does  not  possess  superior  merits  over  the 
simple  sodium  chlorid  solution;  the  active  agent,  free  chlorin,  ob- 
tained in  both  instances  is  the  same.  The  ionized  zinc  of  the  zinc 
chlorid  solution  possesses  no  merits  as  an  antiseptic  agent. 

For  dental  purposes,  a  1  per  cent  solution  of  sodium  chlorid  in 
water  is  best  suited.  Roughly  speaking,  a  scant  teaspoonful  of  salt 
dissolved  in  a  pint  of  boiled  water  answers  the  purpose. 

Electro-Sterilization  Equation. 

In  the  various  communications  treating  on  root  sterilization  by 
electrolysis  the  very  important  questions  concerning  the  time 
during  which  the  current  is  applied,  the  number  of  milliamperes 
employed  and  hacteriologic  tests  of  the  resultant  sterility  are 
usually  vaguely  treated.  To  illustrate  the  author's  contention 
the  following  extracts  picked  at  random  from  recent  publications 
on  this  subject  are  appended : 


ELECTRO-STERILIZATION  507 

A  perfect  method  of  sterilizing  root  canals  is  to  be  found  in  ionic  medi- 
cation. In  a  tortuous  or  constricted  canal  the  application  of  two  or  three 
milliamperes  of  current  for  five  or  six  minutes  is  sufficient  to  produce 
ions  from  a  compound  solution  of  antiseptic  salts  which  will  penetrate  the 
length  of  the  canal  and  sterilize  it  effectively.     (Sturridge.) 

A  current  of  three  milliamperes  for  fifteen  minutes,  using  zinc  or  iodin 
properly  applied,  will  sterilize  a  root  and  surrounding  tissue  as  no  retained 
medication   ordinarily   accomplishes.      (Frank   Price.) 

A  current  of  from  two  to  three  milliamperes  is  then  passed  for  fifteen 
minutes.     (Forbes  Webster.) 

The  Edison  110-volt  current  passing  through  a  rheostat  furnishes  the 
power  by  means  of  which  the  zinc  is  decomposed  and  nascent  chlorid  of 
zinc  forced  through  the  end  of  the  root,  with  the  accompanying  electric 
ions.  This  destroys  the  pathogenic  tissue,  and  leaves  an  environment  in 
which  is  is  impossible  for  micro-organisms  to  exist.  The  electrolytic  action 
is  maintained  for  from  three  to  fifteen  minutes,  depending  on  the  extent 
of  diseased  tissue  that  is  to  be  eradicated.  The  average  strength  of  the 
current  is  about  one  milliampere.     (M.  L.  Ehein,  1911.) 

From  a  careful  perusal  of  the  above  quotations  it  will  be  seen 
that  the  strength  of  the  current  and  the  time  for  its  application 
as  stated  are  empiric  suggestions.  No  proof  is  furnished  concern- 
ing the  resultant  bacteriologic  action  of  the  electrolytic  process, 
and  as  a  consequence  the  term  sterility  as  used  by  the  authors  cited 
is  employed  in  a  purely  arbitrary  manner.  The  process  of  electro- 
sterilization,  therefore,  would  merely  add  another  method  of  em- 
piric medication  to  the  numberless  procedures  in  existence  unworthy 
of  lengthy  discussion,  if  it  could  not  be  definitely  proved  that  it 
would  furnish  unquestionable  evidence  of  obtaining  the  absolute 
sterility  of  an  infected  root  canal.  Fortunately  such  proofs  are 
available,  and  the  establishing  of  this  fact  at  once  places  this  pro- 
cedure far  above  any  other  known  therapeutic  measures  employed 
for  such  purposes. 

When  sterility  of  a  primarily  infected  root  canal  is  spoken  of  in 
the  present  light  of  bacteriologic  knowledge,  the  truth  of  this  as- 
sertion has  to  be  proved  by  rigorous  tests,  otherwise  the  term  ster- 
ility loses  its  significance.  These  tests  are  readily  made  by  obtain- 
ing cultures  at  stated  intervals  from  the  canal  under  treatment 
until  complete  negative  results  of  growth  are  obtained.  Regard- 
ing the  bacteriologic  tests  as  applied  to  electro-sterilization,  the  au- 
thor proceeded  as  follows :  Cultures  of  the  infected  root  canal  were 
made  before  treatment  was  instituted,  and  then  every  five  minutes 
thereafter  for  a  given  period  of  time,  usually  twenty  minutes.  The 
infected  agar  plates  were  incubated  in  the  routine  manner   (see 


508 


PHYSICAL    THERAPEUTICS 


below).  Incidentally,  the  time  of  applying  the  current,  and  also 
its  strength,  were  carefully  noted.  By  comparing  the  results  ob- 
tained, a  definite  relationship  between  the  strength  of  the  current, 
the  time  of  application,  and  the  resultant  sterility  could  be  estab- 
lished. Zierler  deserves  credit  for  having  first  noted  the  inter- 
relationship of  these  factors,  and  he  has  suggested  the  use  of  a 


Fig.   114. 

(Mrs.  A.  B.)  Lower  right  second  bicus- 
pid. Root  canal  is  imperfectly  filled.  An 
area  of  disturbance  is  visible  about  the 
apical  tissues.  Continuous  gnawing  pain, 
increased  on  pressure  (mastication).  X- 
ray  taken   May   16,    1916. 


Fig.   115. 

(Mrs.  A.  B.)  Same  tooth  as  in  Fig.  114. 
Root  canal  received  three  treatments  by 
electro-sterilization;  root-canal  filled.  For- 
mer trouble  has  completely  subsided.  X- 
ray  taken  Jan.  4,  1917.  Again  inspected 
Feb.  20,  1917;  tooth  in  perfect  condition. 


Fig.   116. 

(Mrs.  S.  W.)  Upper  left  first  bicuspid. 
Chronic  pericementitis  with  abscessed  area 
about  the  foramen;  root  canal  filled  with 
pus.  Continuous  pain  for  over  a  week. 
X-ray  taken  July  10,  1916. 


Fig.   117. 

(Mrs.  S.  W.)  Same  tooth  as  in  Fig.  116. 
Root  canal  received  three  treatments  by 
electro-sterilization.  Root  canal  filled.  X- 
ray  taken  January  12,  1917.  On  inspection 
no   further  trouble  found. 


numerical  constant  which  furnishes  a  working  basis  for  its  clinical 
application.  This  constant  is  30.  By  multiplying  the  number  of 
milliamperes  employed  by  the  time  in  minutes  used  in  the  process 
of  obtaining  a  sterile  root  canal,  invariably  a  number  was  obtained 
which  closely  hovered  about  the  figure  30 ;  or,  reversely,  by  divid- 
ing the  constant  30  by  the  number  of  milliamperes  employed,  a 


ELECTRO-STERILIZATION 


509 


quotient  is  obtained  which  gives  the  time  in  minutes  during  which 
the  current  must  be  applied.  Apparently,  a  given  infected  surface 
area  requires  for  its  sterilization  a  specific  amount  of  migrating 
ions;  at  least  this  assertion  can  be  verified  as  far  as  the  germi- 
cidal action  of  ionized  chlorin  is  concerned  in  the  sterilization  of 
infected  root  canals.  Hence  the  numerical  constant  30  may  be 
looked  upon  as  expressing  in  units  the  surface  area  of  an  average 
root  canal.  In  the  author's  experimental  work  and  in  clinical  prac- 
tice he  has  based  his  observations  upon  the  above  principle,  and 
has  collected  sufficient  data  as  proofs  that  the  appended  electro- 
sterilization  equation,  as  this  formula  has  been  termed,  is  a  reliable 
guide  for  the  application  of  these  procedures  in  the  treatment  of 

30 
infected  root  canals : =  T,  the  30  representing  the  numerical 

M.A. 

constant,  m.a.  the  number  of  milliamperes,  and  T  the  time  in 
minutes. 

The  accompanying  tables,  selected  from  experimental  records, 
will  substantiate  these  claims. 


TABLK  A. ELECTRO-STERILIZATION  OF  TEETH  IN  THE  MOUTHS  OF  PATIENTS 


Patient 

Milliamperes 

Electrolyte 

5  min. 

10  min. 

15  min. 

Constant 

No.  1 

0.5 

1%  sod.  chl. 

solution 

+ 

+ 

+ 

0 

"     2 

2.5 

" 

+ 

+ 

0 

371^ 

"     3 

3.0 

" 

+ 

0 

0 

30 

"     4 

3.5 

" 

+ 

0 

0 

35 

"     5 

1.5 

" 

+ 

+ 

+ 

0 

Growth   -{-. 


No  growth  0.     The  inoculated  agar  plates  are  incubated  for  24 
hours  at  40°  C. 


If  the  three  constants  are  added  which  show  sterility=102i^, 
and  the  total  divided  by  the  number  of  patients,  the  average  con- 
stant will  be  34,  which  in  round  figures  may  be  reduced  to  30. 
Various  attempts  were  made  to  materially  lower  this  constant,  but 
so  far  (as  regards  sodium  chlorid  solution)  have  not  been  suc- 
cessful. 

The  above  experimental  work  furnishes  sufficient  proof,  and  this 
fact  is  borne  out  in  clinical  practice,  that  sterility  of  the  walls  of  an 
infected  root  canal  may  be  obtained  by  electro-sterilization.  It 
should  be  borne  in  mind,  however,  that  this  particular  type  of  steril- 
ization means  sterility  of  the  walls  of  the  root  canals  only  and  not 


510 


PHYSICAL    THERAPEUTICS 


-ELECTRO-STERILIZATION    OF    EXTRACTED    TEETH    HAVING    GANGRENOUS 
ROOT    CANALS 


Teeth 


No.  1 

"  2 

"  3 

"  4 

"  5 


Milli- 
amperes 


0.5 

1 

2 
3 
5 


Electrolyte 

5  min. 

10  min. 

15  min. 

25  min. 

l%sod.chl. 

solution 

+ 

+ 

+ 

+ 

" 

+ 

+ 

+ 

0 

" 

+ 

+ 

0 

0 

" 

+ 

0 

0 

0 

" 

0 

0 

0 

0 

Constant 


0 
25 
30 
30 

25 


Growth  +.     No  growth  0.     The  inoculated  agar  plates  are  incubated  for  24  hours 
at  40°  C.     Total  constants:     110:4  =27 3^  average  constant. 

TABLE  C. ELECTRO-STERILIZATION  OF  PLATED  MIXED  CULTURES  OBTAINED  FROM 

GANGRENOUS  ROOT  CANALS  IN  AGAR 


Plate 

Milliamperes 

Electrolyte 

5  min. 

10  min. 

15  min. 

Constant 

No.  1 

1 

1%  sod.  chl. 

solution 

+ 

+ 

+ 

0 

"    2 

2 

" 

+ 

+ 

0 

30 

"    3 

3 

" 

+ 

0 

0 

30 

"     4 

4 

+ 

0 

0 

40 

Growth    +.     No  growth  0.     The  inoculated  agar  plates  contain   1%  sodium 
chlorid  and  are  incubated  for  24  hours  at  40°  C. 
Total  constants:     100:3=33}^  average  constant. 

of  the  entire  tooth  root.  To  prove  the  correctness  of  this  statement, 
which  on  its  very  face  is  self-evident,  tooth  roots  Nos.  2,  3,  and  4  of 
the  experiments  recorded  in  Table  C  were  cut  into  coarse  shavings, 
plated  on  agar,  and  placed  in  the  incubator.  In  twenty-four  hours 
all  three  plates  showed  luxuriant  growth.  Here  will  be  emphasized 
again  what  has  been  stated  in  the  past  at  frequent  intervals :  Com- 
plete sterilization  of  an  infected  tooth  root  in  situ  is  impossible  by 
any  of  the  present  known  methods ;  complete  sterilization  of  the  sur- 
face of  an  infected  root  canal  is  possible  by  electro-sterilization  as 
outlined  above. 

Clinical  Application  of  Electro-Sterilization. 

To  convey  to  the  reader  a  practical  working  knowledge  of  the 
clinical  application  of  the  principles  of  electro-sterilization,  it  is 
probably  best  to  describe  the  actual  modus  operandi  in  detail  as  em- 
ployed in  a  typical  case.  The  patient  being  seated  in  the  chair  is 
covered  by  a  rubber  apron  sufficiently  large  to  reach  over  the  chair 
-arms,  so  as  to  protect  him  from  accidental  shock  by  "grounding" 


ELECTRO-STERILIZATION  511 

the  current.  The  root  canal  of  the  tooth  to  be  treated  must  be  me- 
chanically cleansed  of  its  debris,  and  if  necessary  enlarged  so  as  to 
give  free  access  to  the  wire  electrode.  Before  starting  the  ionizing 
process  it  is  best  to  assure  oneself  of  the  correct  working  of  the 
current  by  bringing  the  two  poles  together  for  a  moment ;  the  mov- 
ing of  the  needle  of  the  milliamperemeter  in  the  right  direction  acts 
as  an  indicator  that  the  apparatus  is  in  working  order.  The  rub- 
ber dam  having  been  adjusted,  the  root  canal  is  now  flooded  with  a 
1  per  cent  saline  solution — an  S.  S.  W.  minium  syringe  is  useful  for 
such  purpose.  The  patient  takes  a  firm  hold  of  the  negative  elec- 
trode with  his  hand,  which  must  not  carry  rings,  bracelets,  etc.  Be- 
fore introducing  the  freshly  flamed  positive  pole  into  the  canal  the 
operator  should  see  for  himself  that  the  knife  switch  is  open,  and 
that  the  controller  is  set  at  zero.  If  the  wire  electrode  fits  the  canal 
too  loosely,  a  few  fibers  of  cotton  moistened  with  salt  water  are 
wrapped  about  it.  The  needle  is  introduced  as  near  to  the  apex  as 
possible,  and  the  knife  switch  is  closed.  The  controller  is  now  very 
slowly  turned  on,  and  the  patient  is  told  to  at  once  raise  his  hand 
when  he  feels  the  slightest  sensation.  The  moving  needle  of  the 
milliamperemeter  will  indicate  to  the  operator  that  the  current  is 
flowing  in  the  right  direction.  When  the  patient  raises  his  hand  the 
controller  is  turned  very  slightly  back,  left  at  this  point  for  about 
half  a  minute,  and  again  very  slowly  turned  forward  until  the 
patient  again  responds,  or  until  the  point  of  tolerance  is  established. 
This  point  the  writer  has  termed  the  "irritation  point."  A  glance 
at  the  milliamperemeter  conveys  to  the  operator  the  number  of  mil- 
liamperes  employed.  The  operator  now  recalls  to  his  mind  the  nu- 
merical constant  30,  and  quickly  calculates  the  time  of  his  particular 
ease  of  electro-sterilization  by  dividing  thirty  by  the  number  of  mil- 
liamperes  employed.  The  resultant  quotient  gives  the  time  in  min- 
utes for  which  the  current  must  be  applied.  Example :  If  patient's 
irritation  point  is  2.5  m.a.,  12  minutes  by  the  watch  are  required 
for  the  sterilization  of  this  particular  root  canal.  If  the  resultant 
quotient  is  a  fraction,  the  writer  recommends  that  the  next  higher 
unit  be  substituted  as  the  indicator  of  the  time.  Each  root  canal  of 
a  multi-rooted  tooth  is  preferably  treated  separately.  If  a  clamp 
electrode  holder  is  employed  to  clasp  the  two  or  three  wires  inserted 
into  the  multi-rooted  tooth  care  should  be  exercised  to  prevent  short- 
circuiting.     To  avoid  polarization  of  the  positive  electrode,  i.  e., 


512  PHYSICAL   THERAPEUTICS 

covering  by  a  film  of  nascent  gases  which  materially  interferes 
with  the  flow  of  the  current,  the  needle  should  be  removed  at  five- 
minute  intervals  (turn  off  current  previously!)  and  wiped  off. 
During  the  process  of  electro-sterilization  a  drop  of  salt  water  should 
be  added  every  few  minutes  to  make  up  for  loss  by  evaporation. 
Care  must  be  exercised  to  prevent  short-circuiting  of  the  current  by 
allowing  salt  water  to  seep  under  the  rubber  dam  and  thus  transfer 
the  current  to  the  gum  tissue.  After  finishing  the  operation  the 
controller  is  slowly  turned  to  zero,  the  knife  switch  is  opened,  and 
the  electrode  removed  from  the  tooth.  Never  remove  the  electrode 
without  having  first  cut  off  the  current,  otherwise  the  patient  re- 
ceives a  disagreeable  shock  or  a  flash  of  light  passing  in  the  eyes. 
On  passing  a  few  fibers  of  cotton  or  a  paper  cone  in  the  root  canal,  a 
pronounced  odor  of  chlorin  should  be  perceptible.  A  wisp  of  cotton 
or  a  cone  wet  with  salt  water  is  placed  into  the  root  canal,  and  the 
latter  is  closed  with  gutta-percha  stopping.  The  treatment  is  to  be 
repeated  within  forty-eight  hours,  and  if  necessary  again  on  the  fifth 
day,  and  the  canal  is  immediately  filled  after  the  last  treatment.  A 
root  canal  should  never  be  filled  immediately  after  the  initial  treat- 
ment; an  interval  of  at  least  twenty -four  hours  should  be  allowed 
before  doing  so.  Migrating  ions  do  not  develop  their  maximum  de- 
gree of  therapeutic  efficiency  within  the  short  period  of  time  during 
which  the  current  is  applied.  It  requires  practically  twenty-four 
hours  to  produce  their  full  activity  within  the  region  of  a  root 
canal  and  its  surroundings.  The  clinical  indications  of  complete 
sterility  are  definite  odor  of  chlorin  and  a  clean  paper  or  cotton 
cone  after  forty-eight  hours'  insertion.  In  doubtful  cases  sterility 
should  be  verified  by  a  bacteriologic  test.  If  a  metal  filling  is  pres- 
ent in  the  tooth  under  treatment,  it  should  be  removed,  because  if 
touched  by  the  electrode  after  the  current  is  turned  on  it  may  be 
short-circuited  through  the  filling,  and  the  patient  will  receive  a 
shock.  Moreover,  the  action  of  the  chlorin  ions  upon  the  metals  of 
the  filling  materials  results  in  the  formation  of  metallic  chlorids, 
which  infiltrate  the  dentin  structure,  producing  discoloration.  This 
IS  particularly  true  in  the  case  of  gold  chlorid  thus  formed,  which 
by  secondary  decomposition  stains  the  tooth  structure  a  deep  purple 
tint. 

When  the  products  of  pulp  decomposition  pass  beyond  the  fora- 
men of  a  tooth,  localized  pathologic  disturbances  of  the  pericemen- 


ELECTRO-STERILIZATION  513 

turn  arise,  which  usually  lead  to  the  formation  of  an  abscess.  With- 
out entering  into  the  further  discussion  of  the  pathology  of  the  dis- 
turbances at  this  moment,  let  us  assume  that  the  disturbances  are 
eradicated  by  establishing  drainage  along  the  lines  of  least  resist- 
ance. If  the  drainage  takes  place  through  the  root  canal,  this  con- 
dition is  spoken  of,  although  wrongly,  as  a  blind  abscess,  while  if  the 
drainage  occurs  through  an  artificially  established  canal  through 
the  bone  and  gum  tissue  a  fistula  results.  Acute  types  of  the 
enumerated  disturbances  yield  readily  to  electro-sterilization,  pro- 
vided the  salt  solution  and  the  positive  electrode  reach  the  seat  of  the 
infection.  For  the  treatment  of  an  abscess  drainage  through  the 
root  canal  the  positive  electrode  is  thrust  through  the  foramen  into 
the  abscess  cavity ;  the  treatment  of  an  abscess  with  a  fistula  requires 
a  somewhat  modified  application.  In  the  latter  case  complete  com- 
munication between  the  root  canal  and  the  mouth  of  the  fistula  must 
be  first  established  by  forcing  warm  salt  water  through  the  canal. 
The  root  canal  is  now  treated  as  outlined  above ;  the  fistula  itself 
requires  a  separate  application  of  the  procedure.  The  positive  elec- 
trode is  passed  into  the  fistula,  entering  at  its  outlet  and  carried 
along  the  fistulous  tract  until  the  root  is  felt,  while  the  negative 
pole,  consisting  of  a  piece  of  copper  wire  surrounded  by  salt  water, 
is  placed  in  the  root  canal.  The  sterilization  equation  for  this  treat- 
ment is  the  same  as  already  outlined.  Usually  the  patient  re- 
quires a  lower  milliamperage  for  such  work.  All  types  of  chronic 
abscesses  will  yield  to  this  method  of  treatment,  provided  the  ne- 
crotic area  involved  is  very  small,  and  that  the  seat  of  disturbance  is 
reached  by  the  electrode  and  by  the  salt  water.  Well  defined  granu- 
lomata,  complicated  by  large  areas  of  necrosis  are  not  benefited  by 
electro-sterilization;  they  require  surgical  interference  as  the  last 
resort.  Root  amputation  is  indicated  for  such  purposes,  and  if 
carried  out  according  to  special  technical  methods,  usually  pro- 
duces most  satisfactory  results. 


PART  IV 
LOCAL  ANESTHESIA 


HISTORY. 

The  elimination  of  pain  during  surgical  operations  is  insepa- 
rably interwoven  with  the  history  of  the  human  race.  It  has 
always  been  the  aim  of  those  interested  in  the  cure  of  bodily  ills 
to  relieve  pain  in  some  empirical  manner.  The  efforts  to  solve 
the  riddle  of  painless  operations  were,  however,  seemingly  so  very 
futile  that  even  as  late  as  1832  Velpeau  was  led  to  express  his 
pessimism  as  follows:  "To  escape  pain  in  surgical  operations  is  a 
chimera,  which  we  are  not  permitted  to  look  for  in  our  time." 
Little  did  he  expect  that  he  stood  at  the  very  threshold  of  the 
discovery  of  anesthesia,  and  that  less  than  a  decade  later  the 
"nirvana"  of  painless  operations  would  be  an  accomplished  fact. 
And  when  Dieffenbach,  in  1847,  wrote  those  classical  words  re- 
garding the  use  of  ether  as  an  anesthetic,  "the  beautiful  dream, 
to  eliminate  pain,  has  become  a  fact — pain,  the  highest  conscious- 
ness of  our  earthly  existence,  its  clearest  conception  of  the  im- 
perfections of  our  body,  it  has  to  bow  low  before  the  powers  of 
the  hum^an  mind,"  the  world  at  large  awakened  to  the  fact  that 
pain  had  been  conquered. 

The  discovery  of  anesthesia  is  essentially  to  be  credited  to  the 
dental  and  medical  profession  of  the  United  States,  and  the  names 
of  Crawford  W.  Long,  Horace  Wells,  William  P.  G.  Morton,  and 
Charles  F.  Jackson  are  inseparably  connected  with  it.  "If 
America  has  contributed  nothing  more  to  the  stock  of  human 
happiness  than  anesthetics,  the  world  would  owe  her  an  everlasting 
debt  of  gratitude,"  said  the  late  Samuel  D.  Gross,  the  eminent 
surgeon,  who  had  ample  opportunity  to  observe  in  his  own 
operating  room  the  most  remarkable  changes  that  followed  the 
introduction  of  anesthetics. 

From    an    historical    viewpoint,    comparatively    few    important 

514 


HISTORY  515 

methods  for  the  purpose  of  locally  obtundiug  pain  are  to  be 
recorded  prior  to  the  introduction  of  cocain.  The  compression  of 
nerve  trunks  for  the  abolition  of  pain  seems  to  be  of  an  old  and 
unknown  origin,  which  was  revived  by  Guy  du  Chauliac  and 
Ambroise  Pare,  and  finally  found  a  permanent  place  in  surgery 
as  the  Esmarch  elastic  bandage.  Physically  reducing  the  tem- 
perature of  a  part  of  the  body  by  the  application  of  cold  was 
instituted  much  later,  Bartholin  and  Severino  introduced  this 
method  in  the  middle  of  the  sixteenth  century.  It  became  a 
lost  art,  however,  until  John  Hunter,  of  London,  again  called 
attention  to  its  benefits  by  demonstrating  it  upon  animals,  yet  the 
idea  never  seems  to  have  occurred  to  him  that  the  samie  agent  might 
be  useful  in  abolishing  human  suffering,  and  Larrey,  the  chief 
surgeon  of  Napoleon's  army,  employed  it  for  amputating  pur- 
poses (1807).  James  Arnott,  in  1848,  utilized  a  freezing  mixture, 
consisting  of  ice  and  salt,  as  a  means  of  producing  local  anesthesia. 
Through  the  efforts  of  Sir  B.  W.  Richardson,  in  1866,  it  was  placed 
on  a  rational  basis  by  the  introduction  of  the  ether  spray.  The 
various  narcotics  which  were  employed  for  internal  purposes  were 
also  made  use  of  as  local  applications.  Mandragora,  henbane, 
aconite,  the  juice  of  the  poppy  head,  and  many  other  analgesic 
drugs  enjoyed  a  world-wide  reputation.  There  is  probably  no 
other  medicinal  plant  around  which  clusters  more  mysterious  and 
quaint  associations  than  mandragora.  It  should  be  remembered, 
however,  that  mandrake,  or  mandragora  (atropa  mandragora), 
must  not  be  confounded  with  American  mandrake,  or  may  apple 
{podophyllum  peltatum),  to  which  it  bears  no  relation. 

Probably  the  oldest  known  dental  prescription  that  was  used 
for  the  purpose  of  abolishing  pain  arising  from  an  aching  tooth 
is  recorded  upon  a  clay  tablet  that  was  found  in  Niffer,  and  its 
age  may  be  approximately  placed  at  2250  B.  C.  Recent  excavations 
that  have  been  made  near  Niffer  and  Babylon  have  brought  to 
light  valuable  information  regarding  the  practice  of  medicine 
under  Hammurabi,  king  of  Babylon,  a  contemporary  of  Abraham. 
The  clay  tablet  is  written  in  the  Babylonian  tongue,  which  was 
the  official  language  of  diplomatic  intercourse  from  the  Euphrates 
to  the  Nile.  The  contents  of  this  tablet  refer  to  the  "worm" 
theory  of  dental  caries,  and  the  treatment  consists  in  filling  the 
painful  cavity  of  the  tooth  with  a  cement    prepared   by    mixing 


516  LOCAL   ANESTHESIA 

powdered  henbane  seed  with  gum  mastic.  While  filling  the  "up- 
per part  of  the  tooth"  suitable  incantations  were  recited.  It  is 
interesting  to  observe  that  the  physiologic  conception  of  this  text 
is  humoral  (hematic),  and  that  the  health  of  the  teeth  is  depend- 
ent upon  the  circulation  within  the  tooth  substance.^  In  Egypt 
the  suet  of  the  crocodile,  locally  applied,  was  believed  to  relieve 
pain,  and  Pliny  refers  casually  to  the  mystic  Lapis  Menipliitis, 
the  stone  of  Memphis,  which,  when  rubbed  on  the  surface  of  the 
skin  in  conjunction  with  sour  wine,  was  said  to  produce  local  anes- 
thetic effects.  Nepenthe,  a  preparation  of  purified  opium,  was 
much  praised  by  the  Greeks.  Alcohol,  in  its  various  forms,  always 
enjoyed  a  wide  reputation  as  a  pain  reliever,  and  seems  to  be  as 
old  as  the  world's  histor3^  In  an  early  Cymric  manuscript,  said 
to  have  been  compiled  by  Howell,  the  physician,  who  was  the 
son  of  Rhyr  and  a  lineal  descendant  of  Einion,  and  which  was 
probably  written  about  the  end  of  the  fifteenth  century-,  among 
a  large  number  of  conjectures  Ave  find  the  following:  "How  to 
extract  a  tooth  without  pain:  Take  some  newts,  by  some  called 
lizards,  and  those  nasty  beetles  which  are  found  in  ferns  in  the 
summer  time.  Calcine  them  in  an  iron  pot,  and  make  a  powder 
thereof.  Wet  the  forefinger  of  the  right  hand,  and  insert  it  in 
the  powder,  and  apply  it  to  the  tooth  frequently,  refraining  from 
spitting  it  off,  when  the  tooth  will  fall  away  without  pain.  It  is 
proven.  "2  During  the  middle  ages  the  following  mixture,  as 
recorded  by  Cardow,  was  frequently  used  as  a  local  anodyne  in  the 
form  of  an  ointment:  "Opium,  celandine,  saffron  marrow  and 
fat  of  man,  together  with  oil  of  lizards."  The  "Herbals"  (books 
on  vegetable  remedies),  of  the  sixteenth  and  seventeenth  centuries 
contain  innumerable  compounds  which  are  recommended  as  spe- 
cific dental  remedies. 

The  empirical  search  for  new  methods  and  means  pressed  the 
mysticism  of  the  electric  current  into  service,  opening  a  prolific 
field  to  the  charlatan,  which  even  to  this  day  has  not  lost  its 
charm.  Richardson's  voltaic  narcotism  for  a  time  attracted  the 
attention  of  the  medical  and  dental  profession.  Its  inventor 
claimed  "that  by  the  action  of  a  galvanic  current,  passing  through 
a  narcotic  solution,  held  in  contact  Avith  the  part  to  be  operated 


*  Von  Oeffele:  Mitteilungen  zur  Geschichte  der  Medizin,  etc.,  1904. 
'  FTermann  Peters:  Der  Ant  und  die  Ilelllcunst,  1900, 


HISTORY  517 

upon,  some  of  the  narcotic  substance  passed  much  more  rapidly 
into  the  tissue,  and  that  in  many  instances  complete  local  anes- 
thesia was  in  this  way  produced  by  solutions  which  are  entirely 
inert  when  applied,  even  to  the  most  delicate  tissue,  without  the 
galvanic  current."  This  very  same  principle,  discovered  by 
Reuss  in  1807,  and  introduced  by  him  as  "electric  endosmosis," 
or  as  " cataphoresis "  by  E.  du  Bois-Raymond,  was  "newly  dis- 
covered" and  reintroduced  into  dentistry  about  two  decades  ago.  In 
cyclonic  fashion  it  swept  over  the  globe,  but  today  it  is  almost 
forgotten.  Electric  or  galvanic  anesthesia  was  suggested  as  far 
back  as  1851  by  A,  Hill,^  of  Connecticut.  Francis,^  in  1858, 
recommended  the  attachment  of  the  electric  current  to  the  well- 
insulated  handles  of  the  forceps  for  the  painless  extraction  of 
the  teeth,  and,  as  dental  depots  still  offer  appliances  of  this  na- 
ture for  sale,  it  seems  that  this  method  is  still  in  vogue  with 
some  operators.  According  to  Regner  and  Didsbury,  as  cited  by 
Sauvez,^  a  current  of  electricity  of  high  frequency,  when  directed 
toward  the  long  axis  of  a  tooth  for  a  shorter  or  longer  period 
previous  to  its  extraction,  produces  insensibility  to  pain.  In  1880 
Bonwill*  suggested  his  method  of  "rapid  breathing  as  a  pain  ob- 
tunder,"  which  he  claimed  "produces  a  similar  effect  to  that  of 
ether,  chloroform,  and  nitrous  oxid  gas  in  their  primary  stages." 
In  the  early  days  of  modern  dentistry  many  feeble  efforts  were 
made  to  alleviate  pain  during  trying  operations.  Chloroform, 
alcohol,  ether,  aconite,  opium,  the  essential  oils,  and  many  other 
drugs  were  the  usual  means  that  were  employed,  either  separately 
or  as  compounds,  usually  under  fanciful  names,  for  such  pur- 
poses. Snape's  calorific  fluid,  composed  of  chloroform,  tincture 
of  lemon  balm,  and  oil  of  cloves;  naholis,  consisting  of  gly- 
cerite  of  tannic  acid  and  a  small  quantity  of  chloral  hydrate ;  Mor- 
ton's  letJieon,  which  was  sulphuric  ether  mixed  with  aromatic 
oils,  are  examples  of  proprietary  preparations  Avhich  enjoyed  quite 
a  reputation  in  their  time.''  In  1844,  F.  Rynd,  an  Irish  surgeon, 
introduced  a  method  of  general  medication  by  means  of  hypo- 
dermic injections,  Avhich,  in  1853,  was  much  improved  by  Alex- 


»HilI:  New  York  Dental  Record,  Vol.   VI,  p.  145. 

»  Francis:  American  Journal  of  Dental  Science,  2d  Series,  Vol.  VHJ,  p.  433. 

'Sauvez:  A  Study  of  the  Rest  Means  of  Local  Anesthesia,  Paris,  1904. 

<  Bonwill:  American  System  of  Dentistry,  Vol.  Ill,  p.  213. 

«  Flagg-Foulks:   Dental   Pathology,  etc..   1885,  p.   110. 


518  LOCAL   ANESTHESIA 

ander  Wood,  of  Edinburgh,  and  a  few  years  later  the  French  sur- 
geon Pravaz  modified  the  old  style  syringe  for  this  special  purpose, 
which  since  is  known  as  the  "Pravaz"  or  hypodermic  syringe. 
At  once  it  was  suggested  to  apply  such  drugs  as  morphin  or  tinc- 
ture of  opium  for  the  purpose  of  producing  local  anesthesia.  The 
results  were  not  encouraging,  however,  until  cocain  was  advocated. 
Cocain  was  discovered  by  Niemann  in  1859,  but  it  required 
twenty-five  years  to  make  known  the  remarkable  anesthetic  prop- 
erties which  this  alkaloid  possessed  when  applied  in  the  ready 
soluble  form  of  its  hydrochloric  salt.  It  was  on  September  15, 
1884,  that  Carl  Roller,^  of  Vienna,  had  presented  his  epoch-making 
communication  at  the  Ophthalmologic  Congress  at  Heidelberg,  in 
which  he  demonstrated  the  effects  of  cocain  as  a  local  anesthetic. 
With  the  introduction  of  this  drug  into  therapeutics,  local  anes- 
thesia achieved  results  which  v/ere  beyond  expectations,  and  its 
final  adoption  created  a  new  era  in  local  anesthesia. 

MEANS  OF  PRODUCING  LOCAL  ANESTHESIA. 

The  term  anesthesia  (without  sensation),  which  was  suggested 
in  1846  by  that  great  physician-litterateur,  Oliver  Wendell 
Holmes,  to  Dr.  Morton,  is  usually  defined  as  an  artificial  depriva- 
tion of  all  sense  of  sensation,  while  the  mere  absence  of  pain  is 
referred  to  as  analgesia.  Correctly  speaking,  the  term  local  anes- 
thesia is  partially  a  misnomer.  In  producing  local  anesthesia  we 
do  not  fully  comply  with  all  the  requirements  that  anesthesia 
demands,  because  a  part  of  the  sensorium — the  sense  of  touch 
and  that  of  temperature,  for  instance — is  not  fully  abolished. 
Analgesia,  i.e.,  loss  of  sensibility  to  pain  or  absence  of  pain,  would 
be  a  better  term.  The  term  local  anesthesia  has,  however,  ac- 
quired such  universal  recognition  that  it  would  seem  unwise  to 
recommend  a  change. 

Anesthesia  may  be  artificially  produced  by  inhibiting  the 
sensory  nerve  fibers  at  their  central  end-organs  in  the  brain  or 
at  their  peripheral  end-organs  in  the  tissues,  thus  producing  gen- 
eral and  local  anesthesia.  Local  anesthesia  may  be  obtained  in  two 
definite  ways:  We  may  inhibit  the  function  of  the  peripheral 
nerves  in  a  circumscribed  area  of  tissue,   and  we  refer  to  this 


*  Roller:   16th  Uphthalmologenkongress,   Heidelberg,  1884. 


MEANS   OF   PRODUCING   LOCAL   ANESTHESIA  519 

process  as  "terminal  anesthesia,"  while,  if  we  block  the  conduc- 
tivity of  a  sensory  nerve  trunk  somewhere  between  the  brain  and 
the  periphery,  we  speak  of  it  as  "conduction  anesthesia."  Dental 
terminal  anesthesia  is  usually  produced  by  a  subperiosteal  injec- 
tion (indirect  anesthetization)  or  a  peridental  injection  (direct 
anesthetization)  while  conduction  anesthesia  may  be  produced  by 
injecting  into  the  nerve  trunk  proper — endoneural  injection — or 
by  injecting  into  the  tissues  surrounding  a  nerve  trunk — peri- 
neural injection.  The  latter  form  is  the  usual  method  pursued 
when  conduction  anesthesia  for  dental  purposes  is  indicated. 

Local  Anesthesia 


Terminal  anesthesia  Conduction  anesthesia 


Subperiosteal     Peridental  Endoneural      Perineural 

injection  injection  injection  injection 

The  successful  practice  of  local  anesthesia  involves  the  care- 
fully adjusted  cooperation  of  a  number  of  important  details,  each 
one  constituting  a  definite  feature  in  itself,  which,  when  neglected, 
must  necessarily  result  in  failure.  As  a  whole,  the  practice  of 
local  anesthesia  by  the  hypodermic  method  represents  the  composite 
of  the  following  factors: 

1.  A  sterile  solution  of  drugs  possessing  active  anesthetic 
potencies  and  which,  in  their  Composition,  must  correspond  to  the 
physical  and  physiologic  laws  which  govern  certain  functions  of 
the  living  cell. 

2.  A  carefully  selected  sterile  hypodermic  armamentarium. 

3.  A  complete  mastery  of  the  technique. 

4.  A  proper  selection  of  the  correct  methods  of  injection  suit- 
able for  the  case  on  hand. 

5.  Suitable  preparation  of  the  site  of  injection. 

6.  The  complete  cooperation  of  the  patient. 

7.  Good  judgment  of  prevailing  conditions. 

PHYSIOLOGIC  ACTION  OP  ANESTHETICS. 

According  to  more  recent  therapeutic  conceptions,  it  is  gen- 
erally recognized  that  a  drug  or  combination  of  drugs  which  si- 


520 


LOCAL   ANESTHESIA 


multaneously  produce  local  anemia  and  inhibition  of  the  sensory 
nerves  in  a  circumscribed  area  of  tissue  is  the  logical  solution  of 
the  question  of  local  anesthesia.  Certain  important  factors,  how- 
ever, relative  to  the  physiologic  and  physical  action  of  the  solu- 
tion employed  for  hypodermic  injection  upon  the  cell  govern  the 
successful  application  of  such  methods.  It  is  of  prime  impor- 
tance, therefore,  to  comply  with  the  laws  regulating  the  absorp- 
tion of  injected  solutions — osmotic  pressure. 

If  we  separate  two  solutions  of  salt  of  different  concentration 
by  a  permeable  animal  membrane,  a  continuous  current  of  salt 
and  water  results,  which  ceases  only  after  equalization  of  the 
density  of  the  two  liquids — tha^  is,  equal  osmotic  pressure  (ac- 
cording to  the  Boyle- Van 't  Hoff  law)  is  established.  The  current 
passes  in  both  directions,  drawing  salt  from  the  stronger  to  the 


Plasmolysis   of   cells   of   Tradescantia  Discolor.      (Hugo   de   Vries.)      a,   normal   cell; 
b,  beginning  plasmolj'sis;  c,  pronounced  plasmolysis. 

weaker  solution,  and  water  vice  versa,  until  osmotic  equilibrium 
is  obtained.  The  resultant  solutions  are  termed,  according  to 
De  Vries,^  isotonic.  The  latter  studied  these  conditions  carefully 
with  plants,  especially  with  the  leaves  of  tradescantia  discolor. 
It  the  leaves  of  this  plant  are  placed  in  a  fairly  concentrated 
salt  solution,  water  is  removed  from  the  cells  until  the  osmotic 
pressure  of  the  cell  contents  and  the  surrounding  fluid  are  equal- 
ized. The  volume  of  the  cell  is  reduced,  the  cell  protoplasm 
draws  away  from  the  cell  wall,  usually  starting  in  the  corners, 


■"  De   X'ries:    Wissenschaftliche   Botanik    (Jahrbiicher),    1884. 


PHYSIOLOGIC   ACTION    OF    ANESTHETICS  521 

until  it  is  attached  only  by  a  few  strands  to  the  framework.    This 
process  is  called  by  De  Vries  plasmolysis. 

Osmotic  pressure  is  a  physical  phenomenon  possessed  by  water 
and  all  aqueous  solutions,  and  is  dependent  on  the  number  of 
molecules  of  salt  present  in  the  solution  and  on  their  power  of 
dissociation.  In  organized  nature  these  osmotic  interchanges  play 
an  important  factor  in  regulating  the  tissue  fluids  of  both  ani- 
mals and  plants.  The  life  of  the  cell  depends  on  the  continuous 
passage  of  these  tissue  fluids,  which  furnish  the  nutrient  mate- 
rials, consisting  of  water,  salt,  and  albumin.  These  chemicals  are 
normally  present  in  certain  definite  proportions.  The  membrane 
of  the  living  cell  is,  however,  only  semi-permeable — that  is,  the 
cell  readily  absorbs  distilled  Avater  Avhen  surrounded  by  it.  The 
cell  becomes  macerated,  loses  its  normal  structure,  and  finally 
dies.  If,  on  the  other  hand,  the  surrounding  fluid  be  a  highly 
concentrated  salt  solution,  the  solution  absorbs  water  from  the 
cell  only,  and  no  salt  molecules  enter  into  the  cell  body  proper. 
The  cell  contracts  and  finally  dies.  This  process  of  cell  death  is 
in  general  pathology  referred  to  as  necrobiosis.  Another  im- 
portant factor  teaches  that  all  aqueous  solutions  that  are  isotonic 
possess  the  same  freezing  point — that  is,  all  solutions  possessing 
an  equal  freezing  point  are  equimolecular,  and  possess  equal 
osmotic  pressure.  This  law  of  physical  chemistry  has  materially 
simplified  the  preparation  of  such  solutions.  The  freezing  point 
of  human  blood,  lymph,  serum,  etc.,  has  been  found  to  equal  ap- 
proximately 0.55°  C,  which  in  turn  corresponds  to  a  0.85  per 
cent  sodium  chlorid  solution.  Such  a  solution  is  termed  a  physio- 
logic salt  solution.  In  the  older  works  on  physiology  a  0.6  per  cent 
sodium  chlorid  solution  is  referred  to  as  a  physiologic  salt  solu- 
tion, and  corresponds  to  the  density  of  the  blood  of  the  frog.  A 
slight  deviation  above  and  below  the  normal  percentage  of  the 
solid  constituents  is  permissible.  When  physiologic  salt  solution 
at  body  temperature  is  injected  into  the  loose  connective  tissues 
under  the  skin  in  moderate  quantities,  neither  swelling  nor 
shrinking  of  the  cell  occurs.  A  simple  wheal  is  formed,  which 
soon  disappears,  and,  as  no  irritation  results,  consequently  no  ap- 
preciable pain  is  felt.  Other  similar  bodies  that  are  equally  solu- 
ble in  water  act  in  the  same  manner,  with  the  exception  of  the 
salts  of  the  alkali  and  alkaline  earth    metals— as    potassium    or 


522  LOCAL   ANESTHESIA 

sodium  bromid.  The  latter  substances  produce  intense  physical 
irritation,  followed,  however,  by  prolonged  anesthesia,  and  in 
consequence  are  termed  by  Liebreich  painful  anestJietics.  If,  on 
the  other  hand,  simple  distilled  water  is  injected,  only  a  superficial 
anesthesia  is  produced ;  the  injection  itself  is  painful,  and  acts 
as  a  direct  protoplasm  poison  by  maceration  of  the  cell  contents, 
which  results  in  the  death  of  the  cell.  If  distilled  water  ap- 
proximately at  a  ratio  of  10  drams  to  the  pound  of  body  weight 
is  injected  into  dogs,  they  will  succumb  in  a  short  time.  The  in- 
jection of  higher  concentrated  salt  solutions  produces  opposite  ef- 
fects; water  is  removed  from  the  tissues  with  more  or  less  pro- 
nounced pain,  and  followed  by  superficial  anesthesia.  Severe  tis- 
sue disturbances  result,  which  may  terminate  in  necrosis.  Hypo- 
tonic solutions — solutions  containing  less  than  0.9  per  cent  of 
sodium    chlorid — cause   swelling  of   the    tissue,    while   hypertonic 

"^J^         o%^  ^O 

A  B  C 

Fig.   119. 

Diagrams   showing  the   effect  upon  human  red  blood  corpuscles  of    (A)    isotonic, 
(B)   hypotonic,  and   (C)    hypertonic  solutions. 

solutions — solutions  containing  more  than  0.9  per  cent  of  sodium 
chlorid — produce  shrinkage.  These  manifestations  are  propor- 
tionately the  more  intense  the  further  the  solution  is  removed 
from  the  freezing  point  of  the  blood.  Furthermore,  hypotonic 
as  well  as  hypertonic  solutions  require  much  more  time  for  their 
absorption  than  isotonic  solutions,  as  the  osmotic  pressure  has  to 
be  standardized  to  the  surrounding  fluids— that  is,  to  the  isotonic 
index  of  the  tissue  fluids. 

Recent  dental  literature  is  replete  with  suggestions  relative 
to  the  preparation  of  a  phj'siologic  salt  solution  intended  as  a 
base  for  anesthetic  solutions.  Numerous  "new"  and  "improved" 
distilling  apparatus  are  recommended  and  great  emphasis  is  laid 
on  a  special  distilled  water  for  such  purposes.  The  object  of  pre- 
paring a  solution  which  in  its  physico-chemic  relationship  cor- 
responds to  the  tonicity  of  the  fluids  of  the  body  is  not  to  disturb 


PHYSIOLOGIC    ACTION    OP   ANESTHETICS 


523 


the  surface  tension  of  the  surface  colloids  of  the  exposed  cells. 
The  coagulative  and  liquefactive  forces  at  the  cell  surface  should 
be  so  compensated  as  to  remain  physiologically  normal,  i.e.,  to 
preserve  the  vital  equilibrium.  J.  Loeb  has  shown  that  sea-water 
possesses  these  qualities  to  the  highest  degree.  Einger  and  Locke 
have  empirically  suggested  artificial  substitutes.  These  solutions 
usually  contain  very  small  quantities  of  calcium  and  potassium 
chlorid  in  addition  to  the  sodium  chlorid.  The  claims  as  made  for 
the  great  advantage  of  such  solutions  for  local  anesthetic  pur- 
poses are  wholly  ephemeral.  The  minute  quantities  of  the  calcium 
and  potassium  ions  present  in  the  few  cubic  centimeters  which 
constitute  the  average  injection  for  dental  purposes  is  too  small 


Fig.  120. 

Contraction  of  the  heart  of  a  frog.  1,  Effect  of  distilled  water;  2,  Contraction  restored 
by  normal  saline  solution;  3,  Effect  of  distilled  water  again  applied  to  the  heart;  4,  Con- 
traction restored  a  second  time  by  normal  saline  solution.     (After  Pembrey  and  Phillips.) 


to  be  of  any  traceable  influence  on  the  involved  cell  structure.  In 
general  surgery  frequently  200  and  more  cubic  centimeters  of 
physiologic  salt  solution  are  injected  without  ill  results.  Kelative 
to  the  use  of  distilled  water  decidedly  less  emphasis  should  be  placed 
on  the  stilling  process  as  on  the  fact  to  use  a  boiled,  i.e.,  sterile 
water,  ' '  In  practical  medicine  and  surgery  normal  tap-water  saline 
solution,  which  has  been  previously  sterilized  by  boiling,  is  the  most 
suitable  fluid  for  transfusions,  washing  out  the  peritoneal  cavity, 
and  in  some  cases  cleaning  the  cavities  of  wounds."^ 


»  Pembrey  and  Phillips:     The  Physiologic  Action   of  Drugs,   London,    1901. 


524  LOCAL   ANESTHESIA 

Local  anemia,  or  ischemia — a  temporary  constriction  of  circu- 
lation— prevents,  as  it  has  been  experimentally  shown,  the  rapid 
absorption  of  fluids  that  are  injected  into  the  affected  area.  Re- 
tarded absorption  of  the  injected  fluid,  holding  poisonous  drugs 
in  solution,  means  increased  action  of  these  poisonous  drugs 
within  the  injected  area.  Increased  action  denotes  increased 
consumption  of  the  poisonous  drugs,  and,  as  a  consequence,  there 
is  less  danger  from  general  absorption.  The  more  important 
means  applied  for  the  purpose  of  producing  local  anemia  are: 

1.  The  Esmarch  elastic  bandage. 

2.  The  application  of  cold. 

3.  The  extract  of  the  suprarenal  capsule,  or  its  synthetic  sub- 
stitutes. 

Some  observers  have  maintained  that  local  anemia  produces 
anesthesia.  This  is  not  the  case ;  it  is  merely  an  important  means 
to  confine  the  injected  anesthetic  to  the  anemic  region,  and  thus 
bring  about  an  increased  and  prolonged  action  of  the  drug.  Con- 
sequently the  concentration  of  the  anesthetic  solution  may  be  of 
a  lower  percentage,  which,  of  course,  lessens  the  danger  of  in- 
toxication. For  plausible  reasons  the  Esmarch  elastic  bandage 
can  not  be  made  use  of  for  dental  operations. 

Physically  reducing  the  temperature  of  the  body  by  the  appli- 
cation of  cold  (ice  pack,  ice  and  salt  mixture,  cold  metals,  etc.) 
was  practiced  by  the  older  surgeons.  Arnott,  in  1848,  and  Blum- 
dell,  in  1855,  advocated  ice  packs  for  the  painless  extraction  of 
teeth.  Through  the  efforts  of  Sir  B.  W.  Richardson,  in  1866, 
this  method  was  placed  on  a  rational  basis  by  the  introduction  of 
his  ether  spray.  To  obtain  good  results,  a  pure  ether  (boiling 
point  95°  F.,  35°  C),  free  from  water,  is  necessary.  Certain 
other  hydrocarbons  possess  similar  properties  in  varying  degrees, 
depending  on  their  individual  boiling  point.  In  1867  Rotten- 
stein  called  attention  to  the  use  of  ethyl  chlorid  as  a  refrigerating 
agent,  and  Rhein,  in  1889,  introduced  methyl  chlorid  for  the  same 
purpose.  In  1891  Redard  reintroduced  ethyl  chlorid  as  a  local 
anesthetic,  which  since  has  become  known  by  many  trade  names 
as  antidolorine,  kelene,  narcotile,  etc. — and  mixtures  of  the 
first  two  in  various  proportions,  known  as  anestol,  anestile,  coryl, 
metethyl,  etc.,  are  extensively  used  in  minor  oral  and  general  sur- 
gery.   A  pure  ethjd  chlorid  (boiling  point  55°  F.,  13°  C.)  is  best 


PHYSIOLOGIC   ACTION   OP    ANESTHETICS 


525 


suited  for  this  purpose,  as  it  lowers  the  temperature  of  the  tissues 
sufficiently  to  produce  a  short  superficial  anesthesia  in  a  few  min- 
utes. Too  rapid  cooling  or  prolonged  freezing  by  methyl  chlorid 
(boiling  point  — 12°  F.,  — 24.5°  C),  or  the  various  mixtures  there- 
of, produce  deeper  anesthesia,  but  such  procedures  are  dangerous. 
They  frequently  cut  off  circulation  in  the  affected  part  so  com- 
pletely as  to  produce  sloughing  (necrosis).  Liquid  nitrous  oxid, 
liquid  or  solid  carbon  dioxid  (recently  known  as  carbonic  acid 
snow),  and  liquid  air,  all  of  which  have  a  boiling  point  far  below 
zero,  are  recommended  for  similar  purposes,  but  they  require  cum- 
bersome apparatus  and  some  of  these  agents  are  extremely  dan- 
gerous to  use. 

Ethyl  Chlorid  and  Its  Administration. 

Ethyl  Chlorid, — Monochlorethane ;  hydrochloric  ether,  C0H3CI. 
"A  haloid  derivative,  prepared  by  the  action  of  hydrochloric  acid 
gas  on  absolute  alcohol."     At  normal  temperature,  ethyl  chlorid 


Fig.  121. 

Kthyl  chlorid  spray  tube  (glass). 


is  a  gas,  and  under  a  pressure  of  two  atmospheres  it  condenses  to 
a  colorless,  mobile,  very  volatile  liquid,  having  a  characteristic, 
rather  agreeable,  odor  and  burning  taste.  It  boils  at  about  55°  F. 
(13°  C),  and  is  very  inflammable,  burning  with  a  smoky,  green- 
edged  flame.  It  is  stored  in  sealed  glass  or  metal  tubes,  and  when 
liberated  at  ordinary  room  temperature  (70°  F.,  21°  C.)  it  evap- 
orates at  once.  In  commerce  it  is  supplied  in  plain  or  graduated 
glass  tubes  of  from  3  to  60  grams  capacity,  or  stored  in  metal  cyl- 
inders holding  from  60  to  100  grams  or  more-  To  remove  the 
ethyl  chlorid  from  the  hermetically  sealed  smaller  tubes,  the  neck 


526 


LOCAL   ANESTHESIA 


has  to  be  broken  off,  while  the  larger  glass  and  metal  tubes  are 
provided  with  suitable  stop  cocks  of  various  designs  to  allow  def- 
inite amounts  of  the  liquid  to  be  released. 

Mode  of  Application. — For  the  extraction  of  teeth,  immediate 
removal  of  the  pulp,  opening  of  abscesses,  and  other  minor  opera- 
tions about  the  oral  cavity,  the  tube  should  be  warmed  to  body 
temperature  by  placing  it  in  heated  water,  and  its  capillary  end 
should  be  held  about  six  to  ten  inches  from  the  field  of  operations. 
The  distance  depends  on  the  size  of  the  orifice  of  the  nozzle,  and 
complete  vaporization  should  always  be  produced.  The  Gebauer 
tube  is  fitted  with  a  spray  nozzle,  which  shortens  the  distance  to 
one  to  two  inches,  and  is  especially  well  adapted  for  dental  pur- 
poses.    The  stream  is  directed  upon  the  tissues  until  the  latter 


Fig.   122. 
Ethyl  chlorid  spray  tube  (metal). 


are  covered  with  ice  crystals  and  have  turned  white.  For  the  ex- 
traction of  teeth  the  liquid  should  be  projected  directly  upon  the 
surface  of  the  gum,  as  near  to  the  apex  of  the  root  as  possible, 
but  care  should  be  taken  to  protect  the  crown  of  the  tooth  on  ac- 
count of  the  painful  action  of  cold  on  this  part.  Tissues  to  be 
anesthetized  should  first  be  dried  and  well  surrounded  by  a  film 
of  vaselin  or  glycerin,  and  protected  by  cotton  rolls  and  napkins, 
to  prevent  the  liquid  from  running  into  the  throat.  Let  the  pa- 
tient breathe  through  the  nose.  Occasionally  light  forms  of  gen- 
eral anesthesia  are  induced  by  inhaling  the  vapor.  On  account 
of  the  difficulty  of  directing  the  stream  of  ethyl  chlorid  upon  the 
tissues  in  the  posterior  part  of  the  mouth,  it  is  not  successfully  ap- 
plied in  those  regions.  The  intense  pain  produced  by  the  extreme 
cold  prohibits  its  use  in  pulpitis  and  acute  pericementitis.  To 
anesthetize  the  second  and  third  branch  of  the  fifth  nerve,  it  is 
recommended  to  direct  the  stream  of  ethyl  chlorid  upon  the  cheek 


PHYSIOLOGIC    ACTION    OF    ANESTHETICS 


527 


in  front  of  the  tragus  of  the  ear,  but  the  author  has  not  seen  any 
good  results  from  such  a  procedure.  Caution  should  be  exercised 
in  using  ethyl  chlorid  near  an  open  flame  or  in  conjunction  with 
the  thermo-cautery,  as  severe  burns  have  resulted  by  setting  the 
inflammable  vapor  on  fire. 


Fig.   123. 
Application  of  the  ethyl  chlorid  spray. 

The  Active  Principle  of  the  Suprarenal  Capsule  and  its  Sjoithetic 

Substitutes. 

Within  the  last  decades  the  active  principle  of  the  suprarenal 
capsule  has  evoked  extensive  comments  in  therapeutic  literature. 
It  has  been  isolated  by  a  number  of  investigators  under  different 
names,  as  epinephrin  by  Abel  (1897),  suprarenin  by  Fuerth  (1898), 
and  adrenalin  by  Takamine  and  Aldrich    (1901).     Many  other 


528  LOCAL   ANESTHESIA 

titles  are  given  to  this  alkaloid — as  adnephrin,  adrin,  paranephrin, 
suprarenalin,  hemostasin,  epinin,  etc.  Epinephrin  is  a  grayish- 
white  powder,  slightly  alkaline  in  reaction,  and  perfectly  stable 
in  dry  form.  It  is  sparingly  soluble  in  cold  and  more  soluble  in  • 
hot  water,  is  insoluble  in  ether  or  alcohol,  and  with  acids  it  readily 
forms  soluble  salts.  The  preparation  that  is  employed  mostly  for 
therapeutic  purposes  is  a  1 : 1,000  solution  of  epinephrin  hydro- 
ehlorid  in  a  physiologic  salt  solution,  to  which  preservatives — as 
small  quantities  of  chloretone,  thymol,  etc.— are  added.  Alkali  of 
any  kind  is  especially  destructive  to  this  sensitive  alkaloid;  even 
the  small  quantities  of  free  alkali  present  in  ordinary  glass  are 
dangerous.  Bottles  intended  for  storing  epinephrin  solutions 
should  be  made  of  amber-colored  alkali-free  or  Jena  glass  or  bottles 
of  ordinary  glass  should  be  immersed  in  a  diluted  solution  of  hy- 
drochloric acid  for  a  few  days  and  then  thoroughly  washed  in  run- 
ning water  before  they  are  used.  Epinephrin  solutions  do  not 
keep  w^ell.  On  exposure  to  air  and  to  light  they  are  easilj'  decom- 
posed, becoming  pink,  then  red,  and  finally  brown,  and  Avitli  this 
change  of  color  their  physiologic  property  is  proportionally  de- 
stroyed. If  the  epinephrin  solution  be  further  diluted,  it  often 
becomes  practicall}'  worthless  within  a  few  hours. 

When  epinephrin  is  injected  into  the  tissues,  even  in  extremely 
small  doses,  it  temporarily  raises  the  arterial  blood  pressure,  act- 
ing as  a  powerful  vaso-constrictor  by  stimulating  the  smooth  mus- 
cular coat  of  the  blood  vessels,  and  thus  produces  local  anemia. 
Large  doses  finalh'^  reduce  the  blood  pressure,  and  heart  failure 
results.  The  respiration  at  first  quickly  increases,  but  slows  dovni 
and  finally  stops  with  expiration.  Its  action  is  largely  confined 
to  the  smooth  muscle  fibers  of  the  peripheral  vessels.  Epinephrin 
is  destroyed  by  the  living  tissue  cells,  the  body  ridding  itself  of 
the  poison  in  some  unknown  manner.  While  epinephrin  does  not 
possess  local  anesthetic  action,  it  increases  very  markedly  the  effect 
of  certain  anesthetics  when  combined  with  them.  These  observa- 
tions are  of  vast  importance  in  connection  with  the  production  of 
local  anesthesia.  Carpenter.^  Peters.-  Moller,^  and  others  referred 
to  the  use  of  adrenalin  in  this  respect,  and  finally  Braun,*  in  1902, 


*  Carpenter:  Dental  Review,  1901,  No.   6. 

*  Peters:  British  Journal  of  Dental   Science,  1902. 

*  Moller:  Deutsche  Monatsschrift  fiir  Zahnheilkunde,  1902,  No.  9. 
•Braun:  Archiv  fur  Klinische  Chirurgie,  1902,  p.  69. 


PHYSIOLOGIC    ACTION    OP    ANESTHETICS  529 

published  his  classic  researches,  and  to  him  and  his  coworkers, 
specially  Heinze  and  Lawen/  belongs  the  credit  of  establishing 
a  rational  basis  for  the  production  of  local  anesthesia.  It  is  claimed 
that  secondary  hemorrhage  frequently  occurs  after  the  anemia 
produced  by  the  epinephrin  has  subsided,  and  that  the  tissues 
themselves  suffer  from  the  poisoning  effects  of  the  di'ug,  resulting 
in  necrosis.  Such  results  are  produced  only  by  the  injection  of 
too  large  quantities  of  the  di'ug,  which  by  their  deeper  action  close 
up  the  larger  arteries.  The  prolonged  anemia  will  give  way  to 
;i  dilatation  of  the  blood  vessels,  and,  if  the  tissues  are  too  long 
deprived  of  the  circulation,  we  are  able  to  understand  why  slough- 
ing may  result.  Small  doses  of  epinephrin  have  no  effect  upon 
the  tissues  or  on  the  healing  of  a  wound.  Palpitation  of  the  heart 
and  muscular  tremor,  which  were  occasionally  noticed  in  the  early 
period  of  the  use  of  the  drug,  are  the  direct  result  of  too  large 
(loses.  Eccently  a  synthetic  epinephrin  has  been  successfully  pre- 
pared by  Stolz,^  which,  Avith  hydrochloric  acid,  forms  a  stable  and 
readily  soluble  salt.  It  is  marketed  by  the  Farbwerke-Hoechst 
Company,  of  New  York,  as  synthetic  suprarenin  hydrochlorid.  The 
new  chemical  has  been  carefully  tested  physiologically  and  in  clini- 
cal work,  and  the  general  consensus  of  opinion  points  to  the  fact  that 
it  is  not  alone  equal,  but  in  certain  respects  superior,  to  the  organo 
preparations.  Synthetic  suprarenin  solutions  may  be  readily 
sterilized  by  boiling.  They  are  relatively  stable,  and  their  chemic 
purity  insures  uniform  results.  They  are  comparatively  free  from 
dangerous  side  actions.  Our  own  observations  regarding  the  value 
of  synthetic  suprarenin  relative  to  its  actions  and  its  general  be- 
havior is  in  full  accordance  with  the  above  statements,  and  its 
advantages  over  the  organo  preparations  has  led  us  to  adopt  it  ex- 
clusively as  a  component  in  the  preparation  of  local  anesthetic  solu- 
tions. For  dental  purposes— that  is,  for  injecting  into  the  gum 
tissue- — the  dose  may  be  limited  to  one  drop  of  the  epinephrin  solu- 
tion (1  :],000)  or  the  synthetic  suprarenin  solution  (1 :1,000)  added 
to  each  cubic  centimeter  of  the  anesthetic  solution,  five  drops  being 
approximately  the  maximum  dose  to  be  injected  at  one  time. 

The  dosage  of  the  relative  amounts  of  epinephrin  solution  may 
be  arranged  as  follows: 


*Lawen:   Archiv  fur*  Kxperimenfale   Pathologic,    1904,    Vol.    II. 
»Stolz:    Bericht  der   Chemischen   Gesellschaft,   1904.   p.   4149. 


530  LOCAL    ANESTHESIA 

Add  1  drop     of  epinephrin  to     1  C.c.  of  the  novocain  solution. 
"      2  drops  "  "  II      ^    II      ii     ti  (t  ,1 

t(  O  H  II  II  <(    2  li  ((     <<        <(  << 

II      ^   <<   <<    <<      ((      g    ({      ee     <(    <<       <( 

"     5      "      "         "  "   10  or  more  C.c.  of  the  novocain  solution. 

LOCAL  ANESTHETICS. 

Ever  since  the  introduction  of  cocain  into  materia  medica  for 
the  purpose  of  producing  local  anesthesia,  quite  a  number  of  sub- 
stitutes have  been  placed  before  the  profession,  for  which  superi- 
ority in  one  respect  or  another  is  claimed  over  the  original  cocain. 
The  more  prominent  members  of  this  group  are  tropa-cocain,  the 
eucains,  acoin,  nirvanin,  alypin,  stovain,  novocain,  and  quinin 
and  urea  hydrochlorid.'  None  of  these  compounds,  with  the  ex- 
ception of  novocain,  has  proven  satisfactory  for  the  purpose  in 
view.  The  classic  researches  of  Braun  have  established  certain 
facts  which  are  essential  as  regards  the  therapeutic  value  of  a 
local  anesthetic.  The  principal  properties  of  a  modern  local  anes- 
thetic must  correspond  to  the  following  claims: 

1.  In  comparison  with  its  local  anesthetic  value,  it  must  be 
less  toxic  than  cocain,  and  the  difference  of  toxicity  must  be  ab- 
solute— that  is,  the  quantity  of  the  chemical  necessary  to  produce 
the  same  anesthetic  effect  as  a  definite  quantity  of  cocain  must  be 
less  toxic  to  the  amount  of  body  weight. 

2.  The  chemical  must  be  absolutely  indifferent  to  the  tissues 
when  injected  in  more  or  less  concentrated  solution,  and  the  prog- 
ress of  wound  healing  must  not  be  interfered  with  by  the  solution. 

3.  The  chemical  must  be  readily  soluble  in  water,  the  solution 
must  be  comparatively  stable,  and  it  should  be  possible  to  sterilize 
it  by  simple  means. 

4.  The  chemical  must  be  tolerant  to  the  additions  of  epinephrin 
without  interfering  with  the  vaso-constrictor  power  of  the  latter 
drug. 

5.  When  applied  to  mucous  surfaces,  ready  penetration  of  tlic 
chemical  is  necessa^5^ 

There  is  at  this  moment  no  need  to  enter  into  the  pharmaco- 
logic action  of  the  drugs  usually  classified  as  local  anesthetics. 
(See  pages  309.  et  nit.)    Let  it  suffice  to  state  how  the  above-men- 


'  The  materia  medica  of  local  anesthetics  is  more  fully   discussed   on  pages  312,   et  alt. 


LOCAL   ANESTHETICS  531 

tioned  chemicals  fulfill  the  demands  of  Braun.  Tropa-cocain  is 
less  poisonous,  but  also  less  active,  than  cocain,  and  completely 
destroys  the  action  of  epinephrin.  The  eucains  partially  destroy 
the  action,  and  are,  comparatively  speaking,  equally  as  poisonous 
as  cocain.  Acoin  is  irritating  to  the  tissues,  and  much  more  poi- 
sonous than  cocain.  Nirvanin  possesses  little  anesthetic  value. 
Alypin  and  stovain  are  closely  related,  and  when  injected  they 
produce  severe  pain  and  occasionally  necrosis.  This  is  equally 
true  of  quinin  and  urea  hydrochlorid.  Novocain  fully  corre- 
sponds to  every  one  of  the  above  claims ;  its  toxicity  is  about  six  to 
seven  times  less  than  cocain;  it  does  not  irritate  in  the  slightest 
degree  when  injected,  and  consequently  no  pain  is  felt  from  its 
injections,  per  se;  it  is  soluble  in  its  own  weight  of  water;  it  will 
combine  with  epinephrin  in  any  proportion  without  interfering 
with  the  physiologic  action  of  the  latter,  and  is  readily  absorbed 
by  the  mucous  membranes. 

The  studies  of  Biberfeld^  and  Braun  brought  to  light  another 
extremely  interesting  factor  concerning  the  novocain-epinephrin 
combination.  Both  experimenters,  working  independent  of  each 
other,  observed  that  the  epinephrin  anemia  on  the  one  hand  and 
the  novocain  anesthesia  on  the  other  hand  were  markedly  in- 
creased in  their  total  effect  on  the  tissues.  Consequently  a  smaller 
quantity  of  this  most  happy  combination  is  required  to  produce 
the  same  therapeutic  effect  than  a  larger  dose  of  each  drug  alone 
would  produce  when  injected  separately;  besides,  the  injection  of 
a  solution  of  the  combined  drugs  is  confined  precisely  to  the  in- 
jected area. 

The  relative  toxicity  of  a  given  quantity  of  cocain  solution  de- 
pends on  the  concentration  of  the  solution.  Reclus^  and  others 
have  clearly  demonstrated  that  a  fixed  quantity  of  cocain  in  a 
5  to  10  per  cent  solution  is  almost  equally  as  poisonous  as  five 
times  the  same  quantity  in  a  1/5  per  cent  solution.  From  the  ex- 
tensive literature  on  the  subject  we  are  safe  in  fixing  the  strength 
of  the  solution  for  dental  purposes  at  1  per  cent.  This  quantity 
of  cocain  raises  the  freezing  point  of  distilled  water  just  a  little 
above  0.1°  C.  To  obtain  an  isotonic  solution  corresponding  to  the 
freezing  point  of  the  blood,  0.8  per  cent  of  sodium  chlorid  must 


iBiberfeld:  Medizinische  Klinik,  1905,  No.  48. 
*Reclus:  L'Anesthesie  Locale  par  la  Cocaine,  1905. 


532  LOCAL   ANESTHESIA 

be  added.  Having  thus  prepared  a  cocain  solution  which  is  equal 
to  the  blood  in  its  osmotic  pressure  on  the  cell  wall,  it  is  now  neces- 
sary to  aid  the  slightly  vaso-constrictor  power  of  the  drug  by  the 
addition  of  a  moderate  quantity  of  epinephrin,  thus  increasing  the 
confinement  of  the  solution  to  the  injected  area  by  producing  a 
deeper  anemia,  for  a  two-fold  purpose — first,  to  act  as  a  means  of 
increasing  the  anesthetic  effect  of  cocain,  and,  second,  to  lessen  its 
toxicity  upon  the  general  system  bj''  slower  absorption.  As  stated 
above,  one  drop  of  epinephrin  added  to  one  cubic  centimeter  of  the 
isotonic  cocain  solution  is  sufficient  to  produce  the  desired  effect. 
A  suitable  solution  for  dental  purposes  may  be  prepared  as 
follows : 

Cocain  hydrochlorid 5  grains   (0.3  Gm.). 

Sodium  chlorid   4  grains   (0.25  Gm.). 

Sterile  water   1  fluidounce   (30  C.c). 

To  each  cubic  centimeter  add  one  drop  of  epinephrin  when 
used. 

As  stated  above,  the  relative  toxicity  of  a  given  quantity  of  co- 
cain in  solution  depends  on  its  concentration,  but  this  peculiarity 
is  not  shared  by  novocain.  The  dose  of  novocain  may  be  safely 
fixed  at  one-third  of  a  grain  for  a  single  injection.  For  dental  pur- 
poses a  11/2  per  cent  solution  is  preferably  employed,  and  as  much 
as  three  grains  of  a  11/^  per  cent  solution  in  combination  with 
epinephrin  have  been  injected  without  any  ill  results.  For  the 
purpose  of  confining  the  injected  novocain  to  a  given  area,  the  ad- 
dition of  epinephrin  in  small  doses  on  account  of  its  powerful  vaso- 
constrictor action  is  admirably  adapted.  It  is  the  important 
factor  which  prevents  the  ready  absorption  of  both  drugs.  An  in- 
jection of  15  drops  of  a  simple  l^/^  per  cent  solution  of  novocain 
labially  into  the  gum  tissue  produces  a  diffuse  anesthesia,  lasting 
approximately  twenty  minutes;  the  same  quantity  with  the  addi- 
tion of  one  drop  of  epinephrin  increases  the  anesthetic  period  to 
about  one  hour  and  localizes  the  effect  upon  the  injected  area. 

A  suitable  solution  of  novocain  for  dental  purposes  may  be  pre- 
pfivod  as  follows: 

Novocain     7  grains   (0.45  Gm.). 

Sodium  chlorid    4  grains   (0.25  Gm.). 

Distilled  water    1  fluidounce  (30  C.c). 

Boil  the  solution. 


LOCAL   ANESTHETICS 


533 


To  each  cubic  centimeter  add  one  drop  of  epinephrin  when 
used. 

Ready-made  solutions  of  cocain  and,  to  some  extent,  of  novo- 
cain will  not  keep  when  frequently  exposed  to  the  air.  A  perfect 
sterile  solution  may  be  made  extemporaneously  by  dissolving  the 
necessary  amount  of  novocain-suprarenin  in  tablet  form  in  a  given 
quantity  of  boiling  physiologic  salt  solution.  A  suitable  tablet 
may  be  prepared  as  follows : 

Novocain 1^4  grain  (0.015  Gm.) . 

Suprarenin  hydrochlorid,  synthetic M200  grain  (0.000054  Gm.). 

One  tablet  dissolved  in  20  minims  (1  cubic  centimeter)  boiling 
physiologic  salt  solution  makes  a  1^2  per  cent  solution  of  novocain 
ready  for  immediate  use. 

Ready-made  sterile  tablets  of  the  above  or  a  similar  composition 
may  be  obtained  from  dental  supply  houses.  These  tablets  must 
be  carefully  protected  against  moisture  and  light. 

Preparation  of  the  Anesthetic  Solution. 

Solutions  for  hypodermic  purposes  should  be  made  fresh  when 
needed.     A  simple  porcelain   crucible  or  a  graduated   porcelain 


Fig.    124. 
Large  and  small  porcelain  dissolving  cups  for  preparing  sterile  novocain  solution. 

dissolving  cup  held  hy  a  suitably  twisted  aluminum  tongue  and 
a  dropping  bottle  constitute  the  simple  outfit  for  this  work.     The 


534 


LOCAL   ANESTHESIA 


dropping  bottle  should  hold  from  one  to  four  ounces.  A  groove 
on  one  side  of  the  neck  of  the  bottle  and  a  vent  on  the  other  con- 
nected with  two  grooves  in  the  back  of  the  stopper  allow  the  con- 
tents to  flow  out  drop  by  drop.  A  quarter  turn  of  the  stopper 
closes  the  bottle  tightly.  The  number  of  drops  present  in  each 
cubic  centimeter  differs  with  the  various  sizes  of  the  dropping 
bottles,  hence  each  bottle  has  to  be  standardized  with  a  tested 
minim  graduate  or  a  tested  burette.     The  standard  number  of 


Fig.   125. 


Fig.   126. 


Fig.   125. — Dropping  bottle. 

Fig.  126. — Glass  measure  for  local  anesthetics.  The  measure  is  marked  for  10,  20, 
30,  or  40  minims.  It  is  useful  for  measuring  anesthetic  solutions,  or  for  dissolving 
tablets   in    stipulated   quantities   of   liquids. 


drops  may  be  marked  on  the  respective  bottle  with  a  carborundum 
stone. 

The  hypodermic  solution  can  be  made  extemporaneously  in  a 
few  seconds  as  follows :  Place  a  tablet  in  the  porcelain  dissolving 
cup,  add  the  necessary  number  of  drops  (1  C.c.)  of  physiologic 
salt  solution,  and  boil  for  a  few  seconds  by  holding  the  cup  above 
the  flame  of  the  burner.  The  solution  is  now  ready  for  immediate 
use. 

Ready-made  sterile  solutions  of  local  anesthetics  are  also  sold  at 


LOCAL   ANESTHETICS 


535 


present,  and  are  marketed  in  hermetically  sealed  ampuls  of  vari- 
ous designs.  To  open  the  ampul,  a  small  groove  is  made  with 
a  file  at  one  end,  which  is  then  readily  broken  off.  The  contents 
are  aspirated  by  inserting  the  syringe  provided  with  the  needle 
directly  into  the  opened  ampul. 

The  practitioner  is  especially  cautioned  in  regard  to  the  use  of 
local  anesthetics  in  the  form  of  ready-made  solutions.  Solutions  of 
cocain,  even  when  rendered  sterile  by  fractional  sterilization,  will 
not  remain  so  after  the  contents  of  the  bottle  are  exposed  to  the 
air  for  a  short  time.     Ready-made  solutions  that  are  sold  in  the 


Fig,  127. 

Hermetically  sealed  glass  ampuls  of  various  types.    They  contain  sterile  anesthetic  solutions. 

shops  under  more  or  less  fanciful  names  require  still  greater  pre- 
caution. The  Food  and  Drugs  Act  (1906)  and  more  recently 
(1915)  the  Harrison  Narcotic  Law  (see  page  97)  require  that 
all  solutions  containing  cocain,  or  any  substitute  thereof,  must  be 
so  labeled.  Most  of  the  many  so-called  safe  and  reliable  anesthetics 
found  in  the  market  contain  cocain  or  its  substitutes  in  varying 
quantities.  The  addition  of  epinephrin  to  a  ready-made  solution 
not  only  destroys  this  alkaloid  in  a  very  short  time,  but  the  prod- 
ucts of  its  decomposition  make  the  solution  still  more  dangerous. 
The  printed  formulas  that  accompany  many  of  the  ready-made 
solutions  of  local  anesthetics  frequently  show  an  utter  disregard 


536  LOCAL   ANESTHESIA 

of  the  pharmacologic  action  of  the  individual  ingredients,  which 
forces  us  to  conclude  that  they  are  a  slur  on  the  intelligence  of  the 
practitioner  who  uses  such  compounds. 

HYPODERMIC  ARMAMENTARIUM. 

A  hypodermic  syringe  that  answers  all  dental  purposes  equally 
well  is  an  important  factor  in  carrying  out  the  correct  technique 


Fig.  128. 
Novocain  armamentarium. 


of  the  injection.  The  injection  into  the  dense  gum  tissue  requires 
often  10  or  more  pounds  of  pressure  as  registered  by  an  inter- 
posed dynamometer,  while  in  pressure  anesthesia  even  greater 
pressure  is  frequently  applied. 


HYPODERMIC    ARMAMENTARIUM 


537 


The  selection  of  a  suitable  hypodermic  syringe  is  largely  a  mat* 
ter  of  choice.  All-glass  syringes,  glass-barrel  syringes,  and  all- 
metal  syringes  are  the  usual  types  found  in  the  depots.  An  all- 
glass  syringe  that  answers  every  reasonable  demand  regarding 
asepsis,  durability,  and  perfect  construction,  and  that  is  giving 
universal  satisfaction,  has  been  recently  brought  out  by  the  S.  S. 
White  Dental  Mfg.  Co.  The  syringe  is  constructed  after  the  well 
known  Luer  pattern,  holding  II/2  C.c.  and  it  is  marked  with  suitable 
divisions  on  the  barrel.  The  piston  and  the  barrel  are  ground  so 
perfectly  that  no  washers  are  required  to  make  water-tight  joints. 


--=-■...     ,_j^* 


Fig.    129. 
The    S.    S.    White   aseptic    all-glass   syringe. 

An  adjustable  finger-rest  is  easily  slipped  over  the  assembled  parts 
which  greatly  assists  in  adjusting  the  needle-opening  in  any  de- 
sired direction  and  in  exerting  pressure  on  the  piston.  The  piston- 
rod,  made  of  solid  glass,  is  sufficiently  long  to  allow  about  two 
inches  of  space  between  the  finger-rest  and  the  piston-top.  This 
space  is  of  importance,  as  it  allows  the  last  drop  of  fluid  to  be 
expelled  under  heavy  pressure  without  tiring  the  fingers.  A  re- 
movable cane-handle,  made  of  metal,  greatly  facilitates  the  exer- 
tion of  pressure  on  the  piston.  The  needle-adapter  carries  a  uni- 
versal thread  so  as  to  accommodate  the  hub  of  the  ordinary  hypo- 


538  LOCAL   ANESTHESIA 

dermic  needles.  The  various  parts  of  the  syringe  may  be  de- 
tached in  a  few  moments  to  allow  sterilization  by  boiling.  Broken 
parts  may  be  replaced  mthout  obtaining  a  complete  new  syringe. 
Glass-barrel  syringes  are  not  to  be  recommended  for  dental  pur- 
poses, as  they  are  too  troublesome  to  keep  in  order.     After  care- 


Fig.  130. 

Thoma  sterilizer  for  hypodermic   syringes,   dissolving  cups,   etc 

fully  testing  most  of  the  all-metal  hypodermic  syringes  offered  in 
the  dental  depots  within  the  last  ten  years  by  means  of  the  pres- 
sure gauge  and  in  clinical  work,  subjecting  the  syringes  to  a 
routine  wear  and  tear,  the  author  has  found  that  the  syringes  of 
the  so-called  "Imperial"  type  are  to  be  preferred  over  other  makes. 
They  are  usually  made  of  nickel-plated  brass,  which,  however,  is 


HYPODERMIC   ARMAMENTARIUM 


539 


a  disadvantage,  as  the  nickel  readily  wears  off  from  the  piston, 
and  exposes  the  easily  corroded  brass.    The  piston  should  prefer- 


Fig.   131. 
All-metal  syringe  and  curved  needle  attachment. 

ably  be  made  of  pure  German  silver.  An  all-metal  syringe  as 
pictured  in  Fig.  131  gives  good  results  in  heavy  pressure  work  and 
can  be  recommended.     The  syringe  holds  40  minims  (2  C.c),  is 


540 


LOCAL  ANESTHESIA 


provided  with  a  strong  finger  crossbar,  and  is  extremely  simple 
in  construction.  The  piston  consists  of  a  plain  metal  rod,  with- 
out a  thickened  or  gi'ound  piston-end  or  packing.  The  packing 
consists  of  leather  washers  inserted  at  the  screw-joint,  and  is 
qviickly  removed  and  replaced  if  necessary. 

The  hypodermic  syringe  requires  careful  attention.     It  is  not 


Fig.   132. 

Dental  hypodermic  needles,     a,  incorrectly  ground  needle  point;  b,  correctly  ground 

needle  point. 


m  .    m 


Fig.   133. 
Hypodermic  needles  of  various  designs  for  dental  purposes. 

necessary  to  sterilize  it  by  boiling  after  each  use,  unless  it  should 
be  contaminated  with  blood  or  pus.  The  simple  repeated  washings 
with  a  mixture  of  8  parts  of  alcohol  and  2  parts  of  glycerin  and 
careful  drying  is  sufficient.  If  the  syringe  is  boiled  all  the  leather 
washers  must  be  removed.  The  syringe  is  best  kept  in  a  covered 
glass  or  metal  case,  and  a  large  baeteriologic  Petri  dish  is  suitable 


HYPODERMIC    ARMAMENTARIUM 


541 


for  this  purpose.  Leather-lined  or  felt-lined  boxes  afford  breed- 
ing places  for  bacteria.  Some  operators  prefer  to  constantly  keep 
their  syringes  in  an  antiseptic  solution  when  not  in  use,  and 
others  prefer  to  place  them  in  a  special  sterilizing  bottle,  which 
bottles  may  now  be  purchased  at  dental  depots.  As  a  suitable 
sterilizing  liquid  for  this  purpose  the  above  referred  to  alcohol- 
glycerin  mixture  is  well  adapted. 

Dental  hypodermic  needles  should  be  made  of  seamless  steel, 
or,  still  better,  of  vanadium-steel,  24  to  26  B.  &  S.  gauge,  and  pro- 
vided with  a  short  razor-edge  point.  Thicker  needles  cause  un- 
necessary pain,  and  thinner  needles  are  liable  to  break.     Iridio- 


—5?' 


Fig.   134. 

Needle  attachments  for  Parke,  Davis  &  Co.'s  syringe,  a,  butt  and  adapter  with  Schim- 
mel  needle;  B,  cross  section  of  butt  and  adapter  with  Schimmel  needle;  c,  Schimmel  needle; 
D,  tube  of  Schimmel  needles;  E,  curved  attachment  for  Schimmel  needles;  P,  cross  section 
of  Schimmel  needles  enlarged;  G,  cap  for  sj'ringe  when  not  in  use. 

platinum  needles  are  preferred  by  many  operators,  as  they  may 
be  readily  sterilized  in  an  open  flame. 

The  needle  should  measure  from  a  quarter  to  a  half  inch.  For 
infiltration  or  conduction  anesthesia  one-inch  needles  are  neces- 
sary, and  curved  attachments  of  various  shapes  are  essential  in 
reaching  the  posterior  parts  of  the  mouth.  The  "Schimmel" 
needles  are  excellent,  but  do  not,  however,  fit  every  syringe.  For 
pressure  anesthesia  special  needles  are  required,  and  may  be  bought 
at  the  depots,  or  quickly  prepared  by  grinding  off  the  steel  needle  at 
its  point  of  reinforcement.    The  sterile  needles  should  be  kept  in 


542  LOCAL   ANESTHESIA 

well-protected  glass  containers.  The  needles  are  sterilized  by  boil- 
ing after  each  use  in  plain  water,  dried  with  the  hot  air  syringe, 
and  immediately  transferred  to  a  sterile  glass  dish.*  The  sterile 
needles  should  not  be  again  touched  with  the  fingers,  and  the  cus- 
tomary wire  insertion  is  unnecessary.  As  stated,  novocain  is  pre- 
cipitated from  its  solution  by  sodium  carbonate.  If  soda,  lysol, 
or  similar  compounds  are  used  for  sterilizing  purposes,  the  syringe 
and  the  needles  must  be  washed  with  sterile  water  to  remove  all 
traces  of  alkali. 

TECHNIQUE  OF  THE  INJECTION. 

Various  methods  of  injecting  the  anesthetic  solution  about  the 
teeth  are  in  vogue.  For  the  sake  of  convenience,  we  may  be  per- 
mitted to  divide  them  as  follows: 

1.  The  subperiosteal  injection. 

2.  The  peridental  injection. 

3.  The  intra-osseous  injection. 

4.  The  mandibular  injection. 

5.  The  infra-orbital  injection. 

6.  The  extra-oral  injection. 

7.  Insufflation  anesthesia  of  the  upper  anterior  teeth. 

8.  The  injection  into  the  pulp. 

Before  starting  any  surgical  interference  in  the  mouth,  the  field 
of  operation  should  be  thoroughly  cleansed  and  sterilized  by 
painting  with  diluted  tincture  of  iodin.  Surgery  owes  the  intro- 
duction of  this  excellent  method  to  Grossich,  of  Trieste.  As  tinc- 
ture of  iodin  is  too  irritating,  a  suitable  diluted  alkaline  solution 
is  preferably  employed.  A  serviceable  mixture  for  such  purposes 
is  made  as  follows : 

Tincture  of  iodin  (U.  S.  P.) i^  ounce  (15  C.c). 

Aceton    1  ounce  (30  C.c). 

Keep  in  glass  stoppered  bottles  and  apply  with  a  cotton  swab. 

Tincture  of  aconite  should  never  be  added  to  such  a  mixture. 
It  should  be  remembered  that  the  sterilization  of  the  field  of  oper- 
ation by  the  above  solution  is  primarily  a  mechanical  procedure; 
the  quick  drying  iodin  solution  glues  the  bacteria  to  the  mucous 
surface  and  its  light  color  does  not  materially  interfere  with  the 
epinephrin  anemia. 


TECHNIQUE   OF    THE   INJECTION  543 

After  the  diagnosis  is  made  the  method  of  injection  best 
suited  for  the  ease  on  hand  is  then  decided  upon.  The  necessary- 
quantity  and  the  concentration  of  the  anesthetic  solution  is  now 
prepared,  and  the  syringe  and  hypodermic  needle  fitted,  ready  for 
the  work.  The  correct  position  of  the  syringe  in  the  hands  of 
the  operator  and  its  proper  manipulation  is  an  important  factor, 
and  has  to  be  acquired  by  practice.  The  hand  holding  the  syringe 
is  exclusively  governed  in  its  movement  by  the  wrist,  so  as  to  al- 
low delicate  and  steady  movements,  and  the  fingers  must  be 
trained  to  a  highly  developed  sense  of  touch.  The  syringe  is 
filled  by  drawing  the  solution  up  into  it ;  it  is  held  perpendicular- 
ly, point  up,  and  the  piston  is  pushed  until  the  first  drop  appears 
at  the  needle  point,  which  precaution  prevents  the  injection  of  air 
into  the  tissues. 

Before  entering  into  a  discussion  of  the  various  methods  of  the 
technique  of  the  injection,  it  is  essential  to  recall  to  one's  mind 
the  anatomic  structure  of  the  alveolar  process,  as  this  factor  plays 
an  important  part  in  the  distribution  of  the  injection  within  the 
bone. 

Anatomic  Structure  of  the  Alveolar  Process. 

Eegarding  the  anatomic  structure  of  the  alveolar  process  of 
both  jaws,  it  should  be  remembered  that  this  bone  is  transitory  in 
structure,  becoming  thinner  with  age,  and  is  very  readily  ab- 
sorbed when  the  teeth  are  removed.  The  process  is  composed 
of  soft,  spongy  cancelloid  bone,  which  is  penetrated  by  Haver- 
sian and  Volkmann's  canals  (the  latter  carrying  the  vessels  of 
Von  Ebner),  and  also  contains  lymph  vessels.  The  anterior  wall 
of  the  alveolar  process  of  the  maxilla  is  a  thin  plate  throughout, 
except  about  the  border  of  the  molar  teeth,  while  the  posterior 
surface  is  reinforced  by  the  intermaxillary  bone  and  palatal  proc- 
esses. In  the  mandible  the  anterior  portion  is  the  thinnest 
part,  while  in  the  molar  regions  the  external  and  internal  ob- 
lique lines  materially  increase  the  thickness  of  this  bone.  Fluids 
injected  into  the  periosteum  covering  the  alveolar  process  pene- 
trate the  bone  by  diffusion,  as  Dzierzawsky^  has  experimentally 
shown  by  employing  methjden  blue  injections,  but  this  diffusion 
occurs  only  when  the  injected  fluid  is  held  under  a  certain  pres- 


*  Dzierzawsky :  See  Braun,  Die  Lokalanasthesie.  1904. 


544 


I.OCAL    ANESTHESIA 


sure  by  the  overlying  tissues.  Penetration  through  this  bone  can 
not  be  expected  from  an  injection  into  a  loose  mucosa,  from  which 
the  fluid  is,  sponge  like,  absorbed.  This  factor  explains  the  failure 
of  the  infiltration  method  of  Schleich  when  applied  about  the  al- 
veolar process. 

The  nerve  supply  of  the  anterior  surface  of  the  maxilla,  in- 
cluding the  teeth  and  gum  tissue,  is  received  from  branches  of  the 
second  division  of  the  fifth  nerve,  known  as  the  superior  maxil- 


Fig.   135. 

Cross  section  of  a  right  lower  jaw.     They  show  the  mesial  surfaces  of  the  teeth  and  their 
relation  to  the  bone  structure.     (Loos.) 


lary.  The  nerve  divides  into  the  posterior,  middle,  and  anterior 
superior  dental  branches.  The  posterior  branch  supplies  the 
molar  teeth,  the  gums,  and  adjacent  buccal  mucosa,  while  smaller 
branches  terminate  in  the  canine  fossa;  the  middle  branch  passes 
along  the  outer  wall  of  the  maxillary  sinus,  supplying  the  bicus- 
pid teeth ;  and  the  anterior  branch,  the    largest,    passes    through 


TECHNIQUE   OP    THE   INJECTION 


545 


a  canal  close  to  the  infra-orbital  foramen  over  the  anterior  wall 
of  the  maxillary  sinus,  and  distributes  its  filaments  to  the  incisor 
and  canine  teeth.  All  the  branches  communicate  with  each  other 
about  the  alveolar  process. 

The  hard  palate,  the  periosteum,  and  the  palatine  gum  tissue 
receive  their  innervation  from  the  anterior  palatine  nerve  from 
Meckel's  ganglion,  which  enters  through  the  posterior  palatine 
foramen  and  the  accessory  palatine  canals,  passing  forward  in  a 


Fig.   136. 
Horizontal  section  through  the  alveolar  process  of  the  lower  jaw.     (I^oos.) 


groove  and  joining  anteriorly  with  the  naso-palatine  nerve  as  it 
emerges  from  the  anterior  palatine  foramina  of  Scarpa. 

The  mandible  receives  its  nerve  supply  from  the  largest  of 
the  three  divisions  of  the  fifth  nerve,  known  as  the  mandibular 
branch  or  the  inferior  dental  nerve.  "From  its  point  of  origin 
it  passes  downward  internally  to  the  external  pterygoid  muscle, 
and,  upon  reaching  a  point  between  the  ramus  of  the  mandible 
and  the  sphenomandibular  ligament,  it  enters  the  inferior  dental 
canal  through  the  posterior  or  inferior  dental  foramen.     Before 


546 


LOCAL   ANESTHESIA 


entering  the  foramen,  two  branches  are  given  off — a  lingual  and 
a  mylohyoid  branch.  The  nerve  is  accompanied  through  the 
inferior  dental  canal  by  the  inferior  dental  artery,  and,  Avhen 
the  mental  foramen  is  reached,  it  terminates  by  dividing  into 
an  incisive  and  a  mental  branch.  Between  the  dental  foramen 
and  the  mental  foramen  the  nerve  gives  off  a  series  of  twigs  to 
the  bicuspid  and  molar  teeth,  and,  by  communicating  with  one 
another  within  the  substance  of  the  bone,  forms  a  fine  plexus. 


U 


Fig.  137. 
The  nerve  supply  of  the  upper  and  lower  jaw. 


The  incisive  branch  follows  the  incisive  arteries  through  the  sub- 
stance of  that  part  of  the  bone  between,  the  mental  foramen 
and  the  symphysis,  and  supplies  the  incisor  and  canine  teeth,  while 
the  mental  branch  passes  forward  to  supply  the  chin  and  lower 
lip."     (Broomell.) 


TECHNIQUE   OF    THE   INJECTION 


547 


Fig.   138. 
The  nerve  and  blood  supply  of  the  hard  palate. 


Subperiosteal  Injection. 

The  subperiosteal  injection  about  the  root  of  an  anterior  tooth 
is  best  started  by  inserting  the  needle  midway  between  the  gin- 
gival margin  and  the  approximate  location  of  the  apex.  Nothing 
is  more  dreaded  by  the  pajtient  than  this  first  puncture.  A  fine, 
very  sharp-pointed  needle  causes  very  little  pain,  and  the  sim- 
ple compression  of  the  gum  tissue  with  the  finger  tip  is  often 
quite  effective.  The  pain  may  be  entirely  obviated  by  pressing 
a  pledget  of  cotton  saturated  with  a  concentrated  novocain  solu- 
tion (20  per  cent),  on  the  gum  tissue  or  by  applying  a  very  small 
drop  of  liquid  phenol  on  the  point  of  puncture.  The  ethyl  chlorid 
spray  may  also  be  used  with  great  advantage  for  such  purposes. 
The  needle  opening  faces  the  bone,  the  syringe  is  held  in  the  right 
hand  at  an  acute  angle  with  the  long  axis  of  the  tooth,  while  the 
left  hand  holds  the  lip  and  cheek  out  of  the  way.  After  punctur- 
ing the  mucosa,  a  drop  of  the  liquid  is  at  once  deposited  in  the 
tissue,  and  the  further,  injection  is  painless.  .  Slowly  and  steadily 
the  needle  is  forced  through  the, gum  tissue  and  periosteum  along 
th,e  alveolar  bone  toward  the  apex  of  the  tooth,  depositing  t}ie 
fluid  under  pressure  close  to  the  bone  on  its  upward  and  return 


548 


LOCAL   ANESTHESIA 


trip — I'injection  tracante  et  continue,  as  Keclus  calls  it.  The 
continuous  slow  moving  of  the  needle  prevents  injecting  into  a 
vein.  Another  injection  may  be  made  by  partially  withdrawing 
the  needle  from  the  puncture  and  swinging  the  syringe  anteriorly 
or  posteriorly,  as  the  case,  may  be,  from  the  first  route  of  the  in- 
jection. This  latter  method  is  especiallj^  indicated  in  injecting 
the  upper  molars.  After  removing  the  needle,  place  the  finger 
tip  over  the  puncture  and  slightly  massage  the  injected  area.  A 
circular  elevation  outlines  the  injected  field.     The  naturally  pink 


Fig.  139. 
Subperiosteal  injection. 


color  of  the  gum  will  shortly  change  to  a  white  anemic  hue,  in- 
dicating the  physiologic  action  of  the  epinephrin  on  the  circula- 
tion. No  wheal  should  be  raised  by  the  fluid,  as  that  would  in- 
dicate superficial  infiltration  and  consequently  failure  of  the 
anesthetic.  A  second  injection  should  always  be  made  into  the 
gum  tissue  surrounding  the  tooth  near  its  free  margin.  The 
alveolar  process  in  this  region  offers  innumerable  minute  openings 
for  the  ready  absorption  of  the  injected  solution. 

As  the  liquid  requires  a  definite  length  of  time  to  pass  through 


TECHNIQUE   OP   THE   INJECTION  649 

the  bone  lamina  and  to  reach  the  nerves  of  the  peridental  mem- 
brane and  the  apical  foramen  of  the  tooth,  from  five  to  ten  minutes 
should  be  allowed  before  the  extraction  is  started.  The  length  of 
time  depends  on  the  density  of  the  surrounding  bone  structure. 
The  progress  of  the  anesthesia  may  be  tested  with  a  fine-pointed 
probe,  and  its  completeness  indicates  the  time  when  the  extraction 
should  be  started. 

The  lower  eight  anterior  teeth  are  comparatively  easily  reached 
by  the  injection.  The  straight  needle  is  inserted  near  the  apex 
of  the  tooth,  the  syringe  is  held  in  a  more  horizontal  position,  and 
the  injection  proceeds  now  as  outlined  above. 

The  lower  molars  require  a  buccal  and  lingual  injection.  The 
needle  is  inserted  midway  between  the  roots,  the  gum  margin,  and 
the  apices.     The   external  and   internal   oblique  lines  materially 


Fig.   140. 
Direction  of  needle  in  the  subperiosteal  injection  about  a  canine. 

hinder  the  ready  penetration  of  the  injected  fluid,  and  therefore 
ample  time  should  be  allowed  for  its  absorption. 

If  two  or  more  adjacent  teeth  are  to  be  removed,  the  injection 
by  means  of  infiltrating  the  area  near  the  gum  fold  directly  over 
the  apices  of  the  teeth  is  to  be  preferred.  It  is  advisable  to  use 
a  half-inch  needle  for  this  purpose,  holding  the  syringe  in  a 
horizontal  position,  so  as  to  reach  a  larger  field  with  a  single  in- 
jection. If  all  the  teeth  of  one  jaw  are  to  be  removed  at  one  sit- 
ting, from  two  to  four  injections,  using  two  or  three  tablets  dis- 


550  LOCAL   ANESTHESIA 

solved  in  from  two  to  five  cubic  centimeters  of  water,  may  be 
necessary,  according  to  circumstances;  for  the  complete  anes- 
thetization of  a  single-rooted  tooth,  one  tablet  of  the  novocain- 
suprarenin  compound  is  sufficient;  and  for  the  molars,  one  and, 
according  to  conditions,  two  tablets  may  be  required.  The  quan- 
tity of  novocain  to  be  injected  at  one  sitting  should  be  limited  to 
three  tablets  (one  grain). 

It  should  be  borne  in  mind  that  the  absorption  of  fluids  in- 
jected into  the  gum  tissue  takes  place  very  rapidly  on  account 
of  the  rich  lymph  circulation  in  these  parts. 

The  injection  into  inflamed  tissue,   into  an  abscess,   and   into 


Fig.   141. 
Subperiosteal  injection  about  an  upper  molar. 

phlegmonous  infiltration  about  the  teeth  is  to  be  avoided'.  The 
injection  into  engorged  tissue  is  very  painful;  the  dilated  vessels 
quickly  absorb  cocain  without  producing  a  complete  anesthesia, 
and  general  poisoning  may  be  the  result.  In  purulent  condi- 
tions the  injection  is  decidedly  dangerous,  as  it  forces  the  infec- 
tion beyond  the  line  of  demarcation.  If  the  abscess  presents  a 
definite  outline,  the  injection  has  to  be  made  into  the  sound  tissue 
surrounding  the  focus  of  infection.  If  a  tooth  is  affected  with 
acute  diffuse  or  purulent  pericementitis,  a  distal  and  a  mesial 
injection  usually  produce  successful  anesthesia  by  blocking  the 
sensory  nerve  fibers  in  all  directions.  Ethyl  chlorid  in  connec- 
tion with  the  injection  is  frequently  helpful,  but  a  painless  ex- 


TECHNIQUE   OF    THE   INJECTION  551 

traction  should  not,  however,  be  promised  in  such  cases.     Conduc- 
tion anesthesia  is  the  correct  procedure  for  such  purposes. 

Some  years  ago  Schleich  introduced  a  special  method  for  the 
purpose  of  thoroughly  infiltrating  the  tissues  with  very  weak 
isotonic  cocain  solutions.  He  injects  the  solution  into  the  sub- 
cutaneous tissue,  thereby  raising  a  definite  circular  wheal;  he  now 
inserts  the  needle  in  the  anesthetized  region,  near  the  periphery 
of  the  wheal,  injecting  again  and  raising  a  second  wheal,  and  thus 
he  continues  until  a  circle  of  wheals  has  been  established  which 
incloses  a  completely  anesthetized  surface.  If  deeper  structures 
are  to  be  operated  upon,  the  anesthetizing  of  these  structures  by 
infiltration  has  to  be  performed  in  the  same  manner.  The  Schleich 
method  can  not  be  employed  with  any  degree  of  success  in  the 
oral  cavity,  and  in  general  surgery  it  is  at  present  largely  aban- 
doned. Schleich  deserves  much  credit  for  having  worked  out  the 
basic  principles  of  local  anesthesia,  and  its  subsequent  wide  use 
in  special  and  general  surgery  is  largely  due  to  his  investigations. 

Peridental  Injection. 

Teeth  or  roots  standing  singly,  or  teeth  affected  by  pyorrhea  or 
similar  chronic  peridental  disturbances,  are  frequently  quickly 
and  satisfactorily  anesthetized  by  injecting  the  fluid  directly  into 


Fig.    142. 
Peridental  injection  about  a  bicuspid. 


the  peridental  membrane.  This  method  is  known  as  peridental 
anesthesia,  and  its  technique  is  very  simple.  In  single-rooted 
teeth  a  fine  and  short  hypodermic  needle  is  inserted  mesially  or 
distally  under  the  free  margin  of  the  gum,  or  through  the  inter- 


552 


LOCAL   ANESTHESIA 


dental  papilla,  into  the  peridental  membrane  between  the  tooth 
and  the  alveolar  wall.  Sometimes  the  needle  may  be  forced 
through  the  thin  alveolar  bone  so  as  to  reach  the  peridental  mem- 
brane direct.  To  gain  access  to  this  membrane  in  teeth  set  close 
together,  slight  separation  with  an  orange  wood  stick  or  other  suit- 
able means  is  often  found  to  be  of  advantage.  In  molars  two  in- 
jections are  essential.  One  puncture  is  made  buccally  between  the 
bifurcation  of  the  roots  near  the  gum  margin,  and  the  same  pro- 
cedure is  repeated  on  the  opposite  side  of  the  tooth.     A  drop  of 


Fig.   143. 

A,    Subperiosteal    injection;    B,    Peridental    injection;    C,    Intraosseous    injection    about    a 

canine. 


fluid  is  now  deposited  in  the  tissue,  and  the  injection  is  slowly 
continued.  To  force  the  liquid  into  the  membrane  usually  re- 
quires a  higher  pressure  than  that  which  is  necessary  for  inject- 
ing into  the  periosteum  covering  the  alveolar  process,  but  the 
quantity  of  the  anesthetic  liquid  is  less  than  that  which  is  required 
for  the  former  injection.  Acute  inflammatory  conditions  of  the 
peridental  membrane  and  its  sequela  prohibit  the  use  of  this 
method.    In  peridental  anesthesia  the  seat  of  the  nerve  supply  of 


TECHNIQUE   OP   THE   INJECTION  553 

the  tooth  is  very  quickly  reached,  and  as  a  consequence  the  results 
obtained  are  in  the  majority  of  cases  extremely  satisfactory,  pro- 
vided that  general  conditions  justify  its  application. 

Intraosseous  Injection. 

To  facilitate  the  passage  of  the  injected  fluid  into  the  bone 
structure  proper,  Otte,^  in  1896,  recommended  a  method  by  which 
he  forces  the  anesthetic  solution  directly  into  the  spongy  cancelloid 
bone.  Otte  terms  this  procedure  the  intraosseous  method  of  injec- 
tion. When  Otte's  paper  was  published,  the  technique  of  local 
anesthesia  was  in  its  infancy,  and  as  a  consequence  his  recom- 
mendations were  soon  forgotten.  Nogue,^  in  1897,  again  called 
attention  to  it  under  the  name  of  anestJiesie  diploique.  This 
method  is  especially  indicated  in  the  anesthetization  of  lower 
molars,  because  the  dense  bony  ridges  on  both  sides  of  the  mandible 
materially  interfere  with  the  ready  penetration  of  the  fluid.  The 
technique  of  the  injection  is  described  by  Otte  as  follows:  After 
the  gum  tissue  is  thoroughly  cleansed  with  an  antiseptic  solution, 
it  is  anesthetized  about  the  neck  of  the  tooth  in  the  usual  man- 
ner. After  waiting  two  or  three  minutes,  an  opening  is  made  into 
the  gum  tissue  and  the  bone  on  the  buccal  side  with  a  fine  spear 
drill  or  a  Gates-Glidden  drill.  The  opening  should  be  made  more 
or  less  at  a  right  angle  with  the  long  axis  of  the  tooth,  a  little 
below  the  apical  foramen  in  single-rooted  teeth  or  between  the  bi- 
furcation in  the  molars.  The  right-angle  hand  piece  is  preferably 
employed  for  this  purpose.  The  drill  should  be  of  the  same  diam- 
eter as  the  hypodermic  needle.  The  gum  fold  is  tightly 
stretched  to  avoid  laceration  from  the  rapidly  revolving  drill.  As 
soon  as  the  alveolar  process  is  penetrated,  a  peculiar  sensation 
conveyed  to  the  guiding  hand  indicates  that  the  alveolus  proper 
is  reached,  and  the  sensation  felt  by  the  hand  is  about  the  same 
as  that  experienced  when  a  burr  enters  into  the  pulp  chamber. 
In  this  artificial  canal  the  close-fitting  needle  of  the  hypodermic 
syringe  is  now  inserted,  and  the  injection  is  made  in  the  ordinary 
way.  The  quantity  of  fluid  used  is  much  less  than  is  usually 
needed  for  a  subperiosteal  injection.  As  has  been  stated  above, 
the  roots  of  the  teeth  are  imbedded  in  a  sieve-like  mass  of  bone 


'Ott6:   Nederlandsche   Tandmeesters   Vereeniging,   1896. 
'  Nogu6:  Anesth^sie  Diploique,   1907. 


554 


LOCAL   ANESTHESIA 


tissue,  which  allows  a  ready  penetration  of  fluid  when  injected 
under  pressure.  Within  ten  minutes  the  peridental  membrane 
and  the  pulp  are  sufficiently  anesthetized  to  insure  a  painless  ex- 
traction. If  an  inflammatory  condition  of  the  involved  area  ex- 
ists, the  injection  should  be  made  into  the  sound  tissue — prefer- 


Fig.  144. 

Perineuria!  injection  about  the  foramen  of  Scarpa  and  about  the  posterior  palatine 
canal.  A,  Insertion  of  needle;  B,  Foramen  of  Scarpa;  C,  Insertion  of  needle;  D,  Posterior 
dental  foramina. 


ably  distally  of  the  tooth- — and,  if  this  should  not  be  sufficient,  an- 
other injection  is  made  mesially  of  the  tooth.  As  in  all  highly 
inflamed  processes  about  teeth,  an  absolutely  painless  extraction 
should  not  be  promised  in  such  cases.  Otte's  intraosseous  method 
of  anesthetization  involves  a  comparatively  simple  technique.    Af- 


TECHNIQUE   OF    THE   INJECTION 


555 


ter  mastering  its  essential  detail^,  good  results  are  universally  ob- 
tained, and  this  method  deserves  to  be  recommended  in  suitable 
cases. 

Injection  Into  the  Mandibular  Nerve. 
The  complete  anesthetization  of  the  third,  and  sometimes  of 
the  second,  lower  molar  by  the  subperiosteal  or  by  the  intraos- 
seous method  is  frequently  fraught  with  much  difficulty  on  account 
o'f  the  bony  ridges  on  both  sides  of  the  teeth,  and  posteriorly  by 
the  compact  bone  of  the  ascending  ramus,  which  forms  a  strong 
barrier  to  the  ready  penetration  of  the  liquid  into  the  bone.  These 
difficulties  are  usually  more  pronounced  in  a  malpost  or  an  im- 


Fig.  145. 

Mandibular  sulcus,  a,  External  oblique  line;  h,  Internal  oblique  line;  c.  Position  of 
the  needle;  d.  Occlusal  plane;  the  dotted  outline  forms  the  boundary  of  the  mandibular 
sulcus.      (Seidel.) 

pacted  third  molar,  while  the  same  tooth  standing  alone  seldom 
presents  difficulties  to  the  ordinary  method  of  injection.  In  the 
latter  case  the  tooth  has  more  or  less  always  moved  toward  the 
median  line.  To  overcome  these  difficulties  Braun,  in  1905,  intro- 
duced a  method  of  centrally  anesthetizing  the  mandibular  and 
incidentally  the  lingual  nerve,  which  since  is  kno^vn  as  the  con- 
duction anesthesia  of  the  mandibular  nerve.  In  describing  the 
technique  of  the  injection,  the  author  has  followed  very  closely 
Braun 's  description  of  this  method. 


556  LOCAL   ANESTHESIA 

By  palpating  the  lingual  surface  of  the  ramus  in  the  mouth 
with  the  finger,  the  anterior  sharp  border  of  the  coronoid  process 
is  easily  felt  about  five-eighths  of  an  inch  posterior  of  the  third 
molar.  The  process  passes  downward  and  backward  of  the  third 
molar,  and  enters  into  the  external  oblique  line.  Mesially  from 
this  ridge  is  to  be  found  a  small  triangular  concave  plateau,  which 
is  facing  downward  and  outward,  being  bound  mesially  by  a  dis- 
tinct bony  ridge  and  covered  with  mucous  membrane.  As  there 
is  no  anatomic  name  attached  to  this  space,  Braun  has  called  it 
the  retromolar  triangle    {trigonum  retromolare) .     In  the  closed 


Fig.   146. 
Relation  of  nerve  and  vessels  in  the  pterygomandibular  space.      (Zuckerkandl.) 

mouth  it  is  located  at  the  side  of  the  upper  third  molar,  and  in 
the  open  mouth  it  is  found  midway  between  the  upper  and  lower 
teeth.  Immediately  back  of  the  mesial  border  of  this  triangle, 
directly  beneath  the  mucous  membrane,  lies  the  lingual  nerve, 
and  about  three-eighths  of  an  inch  farther  back  the  mandibular 
nerve  is  to  be  found.  This  last  nerve  lies  close  to  the  bone,  and 
enters  into  the  mandibular  foramen,  which  is  partially  covered 
by  the  mandibular  spine. 

Before  starting  the  injection  the  patient  should  be  cautioned 
to  rest  his  head  quietly  on  the  headrest  of  the  chair,  as  any  sud- 
den movement  or  interference  with  the  hand  of  the  operator  may 


TECHNIQUE   OF    THE   INJECTION  557 

be  the  cause  of  breaking  the  needle  in  the  tissues.  The  syringe, 
provided  with  a  one-inch  needle,  is  held  in  a  horizontal  position, 
resting  on  the  occluding  surfaces  of  the  teeth  from  the  canine 
backward  and  slightly  toward  the  median  line.  The  needle  is  to 
be  inserted  three-eighths  of  an  inch  above  and  the  same  distance 
back  of  the  occluding  surface  of  the  third  lower  molar,  the  needle 
opening  facing  the  bone.  This  position  will  insure  the  correct 
direction  of  the  needle  point  so  as  to  reach  the  tissues  immediate- 
ly surrounding  the  nerves,  and  not  lose  the  injection  in  the 
adjacent  thick  muscle  tissue.  The  needle  must  always  be  in  close 
touch  with  the  bone,  and  is  now  slowly  pushed  forward,  deposit- 
ing a  few  drops  of  fluid  on  its  way  until  the  ridge  (Fig.  145,  a) 
is  reached.  About  five  drops  of  fluid  are  injected  in  this  imme- 
diate neighborhood  for  the  purpose  of  anesthetizing  the  lingual 
nerve.  The  needle  is  now  pushed  very  slowly  forward,  always 
keeping  in  close  touch  with  the  bone  and  depositing  fluid  on  its 
way,  until  it  is  pushed  in  about  five-eighths  of  an  inch.  It  is 
important  to  carefully  feel  the  way  along  the  bony  wall  of  the 
ramus,  as  the  needle  may  have  to  pass  over  roughened  and  bony 
elevations,  which  afford  attachment  to  the  internal  pterygoid 
muscle.  During  the  injection  the  syringe  should  remain  in  the 
same  horizontal  position  as  heretofore  outlined.  Soon  after  the 
injection,  paresthesia  of  one-half  of  the  tongue  on  the  side  of 
the  injection  occurs,  which  is  soon  followed  by  anesthesia  of  the 
mandibular  nerve.  Paresthesia  of  the  mucous  membrane  and 
half  of  the  lower  lip  is  also  established.  The  pulps  of  the  lower 
teeth,  including  the  canine  and  lateral  incisor,  and  the  gum  tissue 
on  both  sides  of  the  jaw,  are  anesthetized,  including  a  part  of  the 
anterior  floor  of  the  mouth.  The  complete  anesthesia  of  the  two 
nerves  also  anesthetizes  the  whole  alveolar  process  in  this  region. 
About  five  minutes  are  required  for  the  complete  anesthetization 
of  the  lingual  nerve,  and  at  least  fifteen  minutes  for  the  mandibular 
nerve.  Braun  claims  that  the  injection  is  absolutely  free  from  dan- 
ger, while  Romer  states  that  danger  may  arise  if  the  whole  quan- 
tity of  the  solution  should  accidentally  be  injected  into  a  vein. 
This  contingency  is  avoided  by  carefully  following  the  advice  of 
Reclus,  to  never  inject  cocain  solution  unless  the  syringe  is  con- 
stantly moving.     The  quantity  of  anesthetic  fluid  necessary  for 


558 


LOCAL   ANESTHESIA 


this  purpose  is  the  same  as  is  needed  for    any    other    tooth- 
cubic  centimeter  of  the  solution. 


-one 


Fig.   147. 

Horizontal  section  of  a  frozen  head  made  1  cm.  above  the  occlusal  surfaces  of  the 
teeth  of  the  lower  jaw.  a,  Mandibular  sulcus;  b,  Mandibular  vein;  c,  Mandibular  artery; 
d,  Mandibular  nerve;  e.  Ramus;  f,  Internal  pterygoid  muscle;  g,  Lingual  nerve;  h,  Internal 
oblique  line;  i,  External  oblique  line;  j,  Masseter  muscle;  k,  External  pterygoid  muscle; 
1,  Tongue. 

Conduction  anesthesia  of  the  mandibular  nerve  is  possible  only 
when  the  patient  can  open  the  mouth  sufficiently  to  allow  the  ready 
introduction  of  the  syringe.  If  the  tissues  about  the  third  molar  are 
highly  infiltrated  with  inflammatory  exudations,  local  anesthesia 


TECHNIQUE   OF    THE   INJECTION  559 

is  absolutely  prohibited.  If  it  is  insisted  upon,  the  resultant 
failure  should  not  be  attributed  to  the  anesthetic,  but  to  the  faulty 
judgment  of  the  operator.  General  narcosis  by  means  of  nitrous 
oxid,  etc.,  is  to  be  preferred  in  such  conditions,  as  well  as  in  pro- 
nounced trismus,  if  a  painless  operation  is  promised. 

To  successfully  perform  conduction  anesthesia  on  the  mandibu- 
lar nerve  according  to  Braun's  method,  a  thorough  anatomic 
knowledge  of  the  parts  involved  and  an  expert  dexterity  of  tech- 
nical detail,  which  can  be  mastered  only  by  experience,  are  re- 
quired. As  already  stated,  before  starting  the  injection  the  pa- 
tient should  be  cautioned  to  keep   perfectly  quiet.     In  spite  of 


Fig.  148. 
Injection   into  the  mandibular  foramen. 

this  warning,  it  may  happen  that  through  an  unexpected  move- 
ment the  needle  will  break  off  and  become  buried  in  the  tissues. 
Unless  the  broken  piece  can  be  quickly  grasped  by  the  pliers, 
further  attempts  to  find  it  are  usually  unsuccessful,  and  a  search 
for  its  removal  must  be  given  up.  Peckert^  reports  a  few  of  such 
accidents  occurring  at  the  dental  clinic  of  the  Heidelberg  Uni- 
versity. He  claims  that  the  broken  needles  were  simply  left 
undisturbed,  and  they  were  borne  by  the  tissues  without  further 
annoyance.  He  emphasizes,  however,  that  the  needles  used  were 
always  sterile,  and  he  attributes  the  absence  of  future  disturb- 
ances to  this  fact. 

Seidel  employs  on  either  side  of  the  jaw  the  thumb  of  the  left  hand  for 
palpation.    He  justly  recommends  "not  to  allow  the  patient  to  open  the  mouth 

iPeckert:  Deutsche  Zahnarztliche  Wochenschrift,  1908,  No.  4. 


560 


LOCAL   ANESTHESIA 


too  far,  as  the  retromolar  triangle,  and  especially  the  internal  oblique  line,  are 
much  more  easily  felt  when  the  muscles  are  somewhat  at  rest." 

His  technique  consists  of  four  steps: 

(1)  The  insertion  of  the  needle.  The  beginner  usually  selects  the  point  of 
insertion  too  far  mesially.  The  point  never  lies  directly  posterior  to  the  lower 
teeth,  but  always  laterally,  and  close  to  the  nail  of  the  thumb,  which  rests  in 
the  retromolar  triangle  and — at  the  moment  of  the  insertion — is  retracted  so 
far  as  to  uncover  its  mesial  half.  The  needle  strikes  the  bone  directly  under 
the  mucous  membrane;  this  is  the  best  safeguard  for  the  beginner.  The  most 
favorable  height  for  insertion  is  0.75  to  1  cm.  above  the  occlusal  plane  of  the 
lower  teeth.  The  syringe  lies  laterally  to  the  teeth  of  the  same  side.  (See  Fig. 
149^.) 

A  B 


C  D 

Fig.   149. 

Seidel's  technique. 


(2)  Now  the  needle  is  retracted  to  the  submucosa  and  gradually  directed 
mesially  until  the  bone  is  lost.  The  stretching  of  the  tissues  has  the  advantage 
of  pressing  the  advancing  needle  against  the  bone  like  a  rubber  band.  The 
syringe  rests  approximately  on  the  teeth  of  the  same  side     (Fig.  149B.) 

(3)  Swinging  of  the  syringe.  The  syringe  is  now  turned  to  the  opposite 
side  until  the  advancing  needle  again  finds  the  bone,  but  on  the  inner  aspect 
of  the  ascending  ramus.  Whether  the  syringe  rests  on  the  canine,  lateral  in- 
cisor, or  bicuspi-d  of  the  opposite  side  depends  on  the  angle  which  the  ascend- 
ing ramus  forms  with  the  sagittal  plane,  the  most  important  point  being  to 
keep  in  touch  toith  the  bone.     (See  Fig.  149C) 

(4)  Advancing  to  the  sulcus.  In  most  eases  it  is  very  easy  from  this  point 
to  proceed,  without  resistance,  between  bone  and  muscle  to  the  mandibular 
space.     (See  Fig.  149/).) 


TECHNIQUE   OP    THE   INJECTION 


561 


To  anesthetize  the  lingual  nerve  and  to  operate  painlessly,  Seidel  injects  0.5 
C.c.  on  the  way  to  the  sulcus.  There  1.5  C.c.  of  the  solution  is  deposited  under 
steady  backward-and-forward  motion  of  the  needle. 

Certain  anatomic  malformations  of  the  roots  of  the  lower  third 
molars  may,  on  rare  occasions,  be  the  cause  of  very  profuse  ar- 
terial hemorrhage  and  other  serious  damage  as  a  result  of  their 
extraction.  There  are,  as  far  as  the  author  knows,  five  cases  on 
record  in  which  the  developing  tooth  inclosed  in  the  body  of  its 
roots  the  contents  of  the  mandibular  canal — the  artery,  vein,  and 


Fig.   150. 

An  abnormal  course  of  the  mandibular  canal.  The  roots  of  the  third  molar  (a)  are 
united  into  a  cone,  and  the  nerve,  artery,  and  vein  pass  through  a  foramen  formed  in  the 
united  roots.     (I,oos.) 

nerve.  The  extraction  of  a  tooth  possessing  such  malformation 
means  tearing  of  the  vessels  and  the  nerve,  causing  extreme  hemor- 
rhage, excruciating  pain,  and  finally  permanent  insensibility  of 
one-half  of  the  lip.  These  are  the  symptoms  as  recorded  from 
cases  which  occurred  in  the  practice  of  Rose^  in  Munich,  in  1898, 
and  Vorslund-Kjar^  in  Copenhagen,  in  1908. 


•Rose:  See  Witzel,  Entwickelung  der  Kiefer,  etc.,  1907. 
»Kjar:   Dental   Cosmos,   1908. 


562  LOCAL   ANESTHESIA 

The  Infra-orbital  Injection. 

To  reach  the  nerve  plexus  which  passes  through  the  infra-orbital 
foramen  and  furnishes  innervation  to  the  upper  canine  and  incisor 
teeth,  an  injection  is  readily  made  in  this  region  and  it  is  always 
followed  by  the  desired  results.  The  infra-orbital  foramen  is 
easily  located  about  i^  inch  below  the  middle  of  the  inferior  ridge 
of  the  orbit  by  palpating  Avith  the  index  finger  of  the  left  hand ; 
the  lip  is  drawn  up  Avith  the  thumb  and  the  one  and  a  half 
inch  needle  is  inserted  directly  into  the  gum  fold  between  the 
canine  and  the  first  bicuspid  tooth.  Slowly  the  needle  is  forced 
upward,  injecting  a  few  drops  of  fluid  on  its  way  until  the  needle 
point  is  felt  under  the  ball  of  the  compressing  finger  resting  over 
the  foramen.     The  syringe  is  now  slowly  emptied  and  withdrawn. 


Fig.   15L 
Perineurial  injection  about   the   infra-orbital   foramen  and   the  alveolar  foramina. 

After  the  injection,  slight  massage  is  here,  as  in  every  case,  of 
advantage.  To  reach  those  branches  of  the  anterior  superior 
dental  nerve  which  enter  into  the  maxillary  bone,  a  good  sized 
cotton  tampon  saturated  with  a  20  per  cent  novocain  solution  is 
placed  in  the  lower  meatus  of  the  nose  and  left  there  during  the 
operation.  A  few  drops  of  the  anesthetic  solution  injected  about 
the  marginal  gum  tissues  of  the  tooth  or  teeth  under  considera- 
tion will  materially  assist  in  insuring  an  absolute  painless  opera- 
tion. 


TECHNIQUE   OF    THE   INJECTION  563 

The  Extra-oral  Injection. 

Very  recently,  extra-oral  injections  for  the  purpose  of  reaching 
certain  nerve  trunks  more  easily  have  been  recommended  by  some 
dental  surgeons  of  Europe.  Such  procedures  are  recommended  for 
the  infra-orbital  foramen  and  the  mandibular  foramen  by  piercing 
respectively  the  cheek  and  the  tissues  about  the  angle  of  the  jaws. 
For  ordinary  dental  purposes  extra-oral  injections  are  not  called 
for,  hence  the  descriptions  of  these  methods  are  omitted. 

Insufflation  Anesthesia  of  the  Upper  Anterior  Teeth. 

Shortly  after  the  introduction  of  cocain  for  anesthetic  purposes 
(1884),  Petsch,  of  Berlin,  discovered  that  anesthetization  of  the 
lower  nostrils  with  a  cocain  solution  produces  a  more  or  less  pro- 
nounced anesthesia  of  the  upper  anterior  teeth.  After  some  ex- 
perimental work  he  published  his  observations,  and  called  this 
new  procedure  ' '  The  Insufflation  Method  of  Local  Anesthesia. ' ' 
At  this  time  no  one  seemed  to  take  any  notice  of  this  new  method, 
and  it  was  soon  forgotten.  In  1907  Lederer,  of  Prague,  and 
Escat,^  of  Toulouse,  independently  of  each  other,  described  anew 
this  method  of  endonasally  producing  anesthesia  of  the  upper 
front  teeth.  Very  recently  (1908)  M.  de  Terra,^  of  Zurich,  pub- 
lished a  detailed  account  of  this  procedure.  De  Terra's  technique 
is  very  simple.  In  accordance  with  the  anatomic  relations,  the 
right  nostril  is  selected  for  the  right  upper  teeth,  and,  vice  versa, 
the  left  nostril  for  the  left  side.  The  head  of  the  patient  is  slight- 
ly bent  forward,  and  with  a  nose  speculum  the  nostril  is  enlarged, 
thus  exposing  the  nasal  septum  on  the  one  side  and  the  lateral 
cartilage  on  the  other  side.  With  an  absorbent  tampon,  fastened 
on  a  metallic  probe  and  dipped  into  a  "cocain  epinephrin  solution, 
the  tissues  are  slightly  massaged  by  moving  the  tampon  to  and 
fro.  A  slight  tingling  and  disagreeable  sensation  is  produced  for 
a  few  minutes,  accompanied  by  free  lachrimation.  In  from  two  to 
three  minutes  the  anesthesia  of  the  mucous  membrane  of  the  nose 
is  completed.  A  cotton  ball  tied  to  a  short  string  is  now  saturated 
with  the  anesthetic  solution  and  placed  in  the  lower  nostril. 
During  the  time  the  tampon  remains  in  the  nose  the  patient  should 
assume  a  sitting  posture  to  avoid  the  possible  escape  of  some  of 


^Escat:   Dental  Register,   1907,  p.   306. 

'  De  Terra:  Correspondenzblatt  fur  Zahnarrte,   1908,  p.  244. 


564  LOCAL   ANESTHESIA 

the  liquid  into  the  posterior  nares. "  Escat  has  studied  with  the 
utmost  care  the  effects  of  nasal  anesthesia  on  the  teeth,  and  sum- 
marizes the  results  of  his  observations  as  follows : 

1.  In  thirty-six  cases  a  complete  anesthesia  was  obtained  of 
the  central  incisor  and  of  the  canine  on  the  side  corresponding 
to  that  of  the  nasal  fossa  subjected  to  the  action  of  the  anesthetic ; 
also  an  incomplete  anesthesia  of  the  first  bicuspid  adjoining  the 
anesthetized  cuspid,  and  of  the  lateral  incisor  on  the  opposite  side. 

2.  In  eight  cases  the  anesthetized  area  included,  in  addition  to 
the  incisors  and  canine  on  the  corresponding  side  of  the  anes- 
thetized nasal  fossa,  the  incisors  and  canine  on  the  opposite  side. 

3.  In  one  case  the  anesthesia  of  the  incisors  and  canine  on  the 
opposite  side  of  the  anesthetized  nasal  fossa  was  complete,  while 
that  of  the  incisors  and  canine  on  the  corresponding  side  was  in- 
complete. 

In  order  to  explain  this  form  of  anesthesia,  Escat  offers  the 
following  plausible  explanation: 

1.  The  infiltration  of  the  floor  of  the  nose,  the  penetration 
through  the  mucous  lining  and  the  thin  lamina  of  bone,  and  the 
absorption  by  the  lymphatics  carry  the  anesthetic  solution  to  the 
nerves  supplying  the  teeth. 

2.  The  cocain  is  taken  up  directly  by  these  nerves,  which  fur- 
nish branches  to  the  incisors  and  to  the  canine  teeth.  In  order 
to  explain  the  anatomic  mechanism  of  this  form  of  anesthesia, 
Clermont,  of  Toulouse,  undertook  the  study  of  a  large  number  of 
specimens.  He  has  found  that  the  anterior  superior  dental 
branch  of  the  superior  maxillary  nerve,  which  supplies  the  in- 
cisors and  canines,  and  gives  off  a  nasal  branch  which  supplies 
the  mucous  membrane  of  the  anterior  portion  of  the  nasal  cavity, 
is  not  inclosed  deeply  in  the  substance  of  the  maxilla,  but  that,  on 
the  contrary,  it  runs  in  close  proximity  to  the  floor  of  the  nasal 
cavity.  In  twenty-nine  specimens  of  a  series  of  fifty-five  he 
found  the  canal  normally  formed,  but  with  an  extremely  thin 
upper  lamina — so  thin  indeed  that  it  was  transparent  and  easily 
pierced — and  in  thirteen  cases  the  canal  was  really  a  groove,  as 
it  lacked  the  upper  wall,  or  lamina.  This  intimate  relationship 
of  the  anterior  superior  dental  nerve  with  the  nasal  mucous  mem- 
brane explains  satisfactorily,  the  author  says,  the  anesthesia  of  the 
upper  teeth  following  anterior  intranasal  anesthesia,  for  in  47  per 


TECHNIQUE   OF    THE   INJECTION  565 

cent  of  the  cases  the  cocain  tampon  is  separated  from  the  anterior 
superior  dental  branch  by  only  the  mucous  membrane,  and  in  53 
per  cent  of  the  cases  the  tampon  is  separated  from  the  nerve  by  a 
very  thin  lamina  of  the  osseous  tissue,  through  which,  it  is  easy 
to  conceive,  the  cocain  readily  reaches  the  nerve. 

Insufflation  anesthesia  is  not  always  reliable.  Many  patients, 
especially  anemic,  and  extremely  nervous  individuals,  are  highly 
reactive  to  cocainization  of  the  nose,  and  frequently  complain  about 
a  feeling  of  general  malaise,  lasting  for  hours  after  the  anestheti- 
zation. 

Injection  Into  the  Pulp  (Pressure  Anesthesia). 

By  pressure  anesthesia,  pressure  cataphoresis,  pulp  anesthesia, 
or  contact  anesthesia,  as  the  process  is  variously  termed,  we  un- 
derstand the  introduction  of  an  anesthetizing  agent  in  solution  by 


Fig.   152. 
lyoeffler's  pressure  syringe  attachment  for  anesthetizing  the  pulp. 

mechanical  means  through  the  dentin  into  the  pulp  or  directly 
into  the  exposed  pulp  for  the  purpose  of  rendering  this  latter 
organ  insensible  to  pain.  Simple  hand  pressure  with  the  finger 
or  with  a  suitable  instrument,  with  the  hypodermic  syringe  or 
with  the  so-called  high  pressure  syringe,  is  recommended  for  such 
purposes. 

The  term  "pressure  anesthesia,"  as  Ottolengui^  relates,  was 
first  suggested  by  Wm.  James  Morton  at  a  dental  meeting  in  1897, 
and  later  appeared  in  his  work  on  "Cataphoresis."  Its  intro- 
duction into  dentistry,  with  a  description  of  a  practical  method, 
however,  is  to  be  credited  to  Edward  C.  Briggs,  of  Boston,*  who, 
in  1890,  read  a  paper  before  the  Harvard  Odontological  Society, 

iQttolengui:  Items  of  Interest,  1890. 

*  Briggs:  International  Dental  Journal,   1891,  p.  296. 


566 


LOCAL   ANESTHESIA 


entitled:  "Removal  of  the  Pulps  by  the  Use  of  Cocain."  Since 
quite  a  few  claimants  of  this  most  valuable  therapeutic  procedure 
have  appeared,  it  is,  from  an  historic  point  of  view,  of  interest 
to  credit  priority  to  the  right  source.  As  is  frequently  the  case 
with  inventions  of  merit,  priority  is  usually  claimed  by  some  one 
else,  and  so  we  are  informed  in  an  editorial  in  the  Items  of  In- 
terest, 1899,  that  ' '  A  certain  person,  or,  rather,  an  uncertain  per- 
son is  traveling  through  the  West  selling  'a  method  of  painlessly 


Fig.   153. 

An   aqueous   solution   of   eosin    forced   through   dentin    with    a  Jewett-Willcox   syringe. 
Time,  one  and  one-half  minutes.     The  pulp  is  stained.     (Miller.) 


removing  pulps,'  and  charging  twenty-five  dollars  for  the  'secret.' 
The  secret  being  too  good  to  keep,  fraternal  fellowship  has  led 
to  its  exposure.  Pulps  may  be  painlessly  extirpated  (so  Ave  are  in- 
formed by  a  correspondent  who  desires  that  his  name  be  not  pub- 
lished) by  carefully  observing  the  following  instruction" — and 
then  the  editor  describes  a  method  which,  in  its  essential  prin- 
ciples, is  practically  the  same  as  is  utilized  today. 


TECHNIQUE   OF    THE   INJECTION  667 

The  literature  on  so-called  pressure  anesthesia  has  grown  to 
very  large  proportions;  the  following  names,  arranged  in  chrono- 
logical order  according  to  the  year  of  the  publication  of  the  es- 
says, represent  the  more  important  writers  on  this  subject:  Wil- 
liam James  Morton,  R.  Ottolengui,  Otto  Walkhoff,  R.  C.  Young, 
J.  A.  Johnson,  R.  B.  Tuller,  Clyde  Davis,  T.  S.  Phillips,  J.  J.  E. 
DeVries,  H.  A.  Sanders,  11.  J.  Goslee,  W.  D.  Miller,  E.  T.  Loeflfler, 
George  Zederbaum,  J.  B.  Buckley,  W.  A,  Johnson,  L.  H,  Ziegler, 
S.  M.  Weaver,  W.  Price,  C.  G.  Meyers,  George  Koerbitz,  Guido 
Fischer,  and  a  host  of  others. 

Before  describing  the  modus  operandi  of  the  various  methods, 
the  histologic  structure  of  the  dentin  should  be  briefly  recalled. 
Dentin  is  made  up  of  about  72  per  cent  inorganic  salts,  about 
10  per  cent  water,  and  an  organic  matrix  constituting  the  remain- 
ing per  cents.  The  dentin  is  perforated  by  a  large  number  of 
tubules,  radiating  from  the  pulp  cavity  more  or  less  wave-like  to- 
ward the  periphery,  where  they  branch  off,  forming  a  deltoid 
network.  Romer  has  counted  31,500  dentinal  tubules  within  the 
area  of  a  square  millimeter.  The  dentinal  tubules  are  filled  with 
the  processes  of  the  odontoblasts,  and  are  known  at  present  as 
Tomes'  fibers.  As  a  matter  of  historical  fact,  Joseph  Linderer 
described  these  fibers  some  years  prior  to  Tomes'  publication  in 
his  "Handbuch  der  Zahnheilkunde"  (1848),  and  speaks  of  them 
as  " Saftfasern"  (juice  fibers),  which  carry  on  the  metabolic 
changes  in  the  dentin.  The  odontoblasts  form  a  continuous  cover 
over  the  pulp.  The  dentinal  fibrils  are  protoplasmic  in  their 
nature,  and  normally  do  not  carry  sensation  in  the  sense  of  the 
word  as  we  understand  this  term.  We  can  cut,  file,  or  otherwise 
injure  the  sound  dentin  Avithout  much  inconvenience  to  the  pa- 
tient. When  the  fibers  have  become  highly  irritated,  a  mere  touch 
on  the  dentin  may  at  once  call  forth  a  paroxysm  of  pain.  Patho- 
logically, this  condition  is  referred  to  as  hypersensitive  dentin. 
Gysi^  explains  the  theory  of  hypersensation  of  dentin  on  the  fol- 
lowing basis:  The  dentinal  tubules  contain  no  nerves,  but  an  or- 
ganic substance  which  carries  on  metabolic  changes  in  the  dentin. 
The  sensitiveness  of  dentin  is,  therefore,  not  a  physiologic  process, 
and  the  physiologic  sensitiveness  of  a  tooth  is  conceived  only  by 
means  of  the  nerves  of  the  pulp  and  of  the  pericementum.     Sen- 

>Gyst:  Deutsche  Monatsschrift  fiir  Zahnheilkunde,  1905. 


568 


LOCAL   ANESTHESIA 


sitiveness  of  dentin  results  from  pressure,  tension,  or  torsion  on 
the  organic  substance  of  the  tubules,  which  in  turn  convey  the  dis- 
turbance to  the  odontoblasts  and  then  to  the  nerve-endings  of  the 
pulp  proper.  The  contents  of  the  tubules  are  aqueous  in  their 
nature,  and,  as  water  can  not  be  compressed  to  any  appreciable 
extent,  the  organic  substance  confined  in  the  tubules  represents  a 


Fig.   154. 

Section  through   the  root  of  a  molar.      Shows  irregular   (secondary)    dentin.      (Reich.) 
C,  Cementum;  D,U,  Mormal  dentin;  P,  Pulp;  J  D,  Irregular  dentin  in  two  layers   (a,  6). 

fixed,  although  comparatively  easily  mobile,  column  (water  filled 
in  a  tube  one  meter  in  length  can  be  compressed  only  about  Mooo 
millimeter).  As  there  are  no  nerves  in  the  dentin,  the  sensitive- 
ness can  not  be  overcome  by  an  anesthetic,  unless  this  anesthetic 
is  conveyed  through  this  organic  substance  into  the  pulp  proper. 
Substances  which  coagulate    albumin — as  phenol,   silver  nitrate, 


TECHNIQUE   OF    THE   INJECTION 


569 


zinc  chlorid,  etc. — destroy  the  albumin  molecule  with  which  they 
come  in  contact,  but  their  deeper  action  is  more  or  less  cut  short 
by  their  own  coagulum.  If,  however,  drugs  are  applied  which 
are  noncoagulants  and  which  are  absorbed  by  the  organic  con- 
tents of  the  tubules,  and  are  thus  conveyed  to  the  pulp,  they  may 
act  as  direct  protoplasm  poisons,  depending  on  their  individual 
pharmacologic  action — destroying  the  vitality  of  the  pulp  com- 
pletely like  arsenic  trioxid,  or  paralyzing  the  nerve  tissue  like 
cocain. 

Methods  of  Anesthetizing-  the  Pulp. 

1.  The  Pulp  is  Wholly  or  Partially  Exposed. — Isolate  the 
tooth  with  the  rubber  dam,  and  clean  it  with  water  and  alcohol. 
Excavate  the  cavity  as  much  as  possible,  and,  if  the  pulp  is  not 
fully   exposed,  wipe  out  the  cavity  with  chloroform  to  remove 


Points  for  pressure  obtunding  syringe,  a,  An  ordinary  dental  hypodermic  needle  is 
ground  off  at  its  point  of  reinforcement;  b.  Specially  shaped  point  made  to  fit  the  drill 
hole;  c,  Specially  shaped  point  with  attachment  for  rubber  washer. 

fatty  deposits  from  the  cartilaginous  layer  of  dentin,  and  de- 
hydrate with  alcohol  and  hot  air.  Saturate  a  pledget  of  cotton  or 
a  piece  of  spunk  with  a  concentrated  cocain  or  novocain  solution 
(one  novocain-suprarenin  tablet  dissolved  in  5  drops  of  water),  place 
it  into  the  prepared  cavity  and  cover  it  with  a  larger  pledget  of 
cotton,  and  then,  with  a  piece  of  un^oilcanized  rubber  or  gutta- 
percha, and  with  a  suitable  burnisher  or  other  specially  devised 
instrument,  apply  slowly,  increasing  continuous  pressure  from  one 
to  three  minutes.  The  pulp  may  now  be  exposed  and  tested.  If 
it  is  still  sensitive,  repeat  the  process.  Loeffler^  states:  "This 
pressure  may  be  applied  by  taking  a  short  piece  of  orange  wood, 


•Loeffler:  Dental  Digest,   1908,   p.   665. 


570  LOCAL   ANESTHESIA 

fit  it  into  the  cavity  as  prepared,  and  direct  the  patient  to  bite 
down  upon  this  with  increasing  force.  In  this  way  we  can  obtain 
a  well-directed  regulated  force  or  pressure,  and  with  less  discom- 
fort to  the  patient  and  operator."  Loeffler^  has  recently  devised 
attachments,  of  different  sizes  and  shapes,  which  are  to  be  used 
with  the  pressure  syringe.  The  attachment  is  placed  into  the 
cavity,  over  the  exposure  of  the  pulp,  and  cemented  into  place. 
After  the  cement  has  hardened  sufficiently,  the  cocain  solution  is 
forced  to  its  destination  in  the  usual  way.  Loeffler  claims  that 
"the  results  obtained  in  a  number  of  almost  hopeless  cases  have 
been  very  gratifying,  to  say  the  least. ' '  This  method  requires  ex- 
treme care,  as  in  applying  too  much  force  the  tooth  is  liable  to 
be  split.  Miller^  describes  his  method  as  follows :  "After  excavat- 
ing the  cavity  as  far  as  convenient  and  smoothing  the  borders  of 
it,  take  an  impression  in  modeling  compound,  endeavoring  to  get 
the  margins  of  the  cavity  fairly  well  brought  out;  put  a  few 
threads  of  cotton  into  the  cavity  and  saturate  them  thoroughly 
with  a  5  to  10  per  cent  solution  of  cocain,  cover  this  with  a  small 
bit  of  rubber  dam,  and  then  press  the  compound  impression  down 
upon  it.  We  obtain  thereby  a  perfect  closure  of  the  margin,  so 
that  the  liquid  can  not  escape,  and  one  can  then  exert  pressure 
with  the  thumb  sufficient  to  press  the  solution  into  the  dentin." 

2.  The  Pulp  is  Covered  With  a  Thick  Layer  of  Healthy 
Dentin. — With  a  very  small  spade  drill  bore  through  the  enamel 
or  direct  into  the  exposed  dentin  at  a  most  convenient  place,  guid- 
ing the  drill  in  the  direction  of  the  pulp  chamber.  Blow  out  the 
chips,  dehydrate  with  alcohol  and  hot  air,  and  apply  the  hypo- 
dermic or  high  pressure  syringe,  provided  Avith  a  special  needle, 
making  as  nearly  as  possible  a  water-tight  joint.  Apply  slow, 
continuous  pressure  for  two  or  three  minutes.  With  a  burr  the 
pulp  should  now  be  exposed,  and,  if  still  found  sensitive,  the 
process  is  to  be  repeated. 

Regarding  the  principle  of  pressure  anesthesia,  it  should  be  re- 
membered that  we  can  not  force  a  liquid  through  healthy  dentin 
by  a  mechanical  device  without  injury  to  the  tooth  itself.  An 
attempt  to  force  fluids  by  high  pressure  through  sound  living 
dentin  into  a  pulp  will  result  in  failure.     Walkhoff  has  tried  to 


>Loefflert  Dental  Summary,  1906,  Vol.  VII. 
'Miller:  Dental  Register,   1904,  Vol.   IV. 


TECHNIQUE   OF   THE   INJECTION 


571 


force  colored  solutions  into  freshly  extracted  teeth  by  applying 
six  atmospheres  pressure  for  half  an  hour  without  success.  If  a 
cocain  solution  is  held  in  close  contact  with  the  protoplasmic  fibers 
of  the  dentin,  the  absorption  of  cocain  takes  place  in  accord- 
ance with  the  laws  of  osmosis.  The  imbibition  of  the  anesthetic 
is  enhanced  by  employing  a  physiologic  salt  solution  as  a  vehicle. 
Living  protoplasm,  however,  reacts  unfavorably  against  the  ready 
absorption  of  substances  by  osmosis  for  two  reasons:  First,  as 
(iraham  has  shown,  the  albumin  molecule  is  relatively  large  and 
not  easily  diffusible,  and,  second,  as  an  integral  part  of  its  life 
it  possesses  "vital"  resistance  toward  foreign  bodies.  These  bio- 
logic facts,  as  stated  by  Walkhoff,^  describe  in  a  pregnant  man- 
ner some  of  the  most  important  physiologic  functions  of  the  odon- 


Fig.   156. 
Weaver  high   pressure   obtunding  syringe. 

toblasts.  The  accuracy  of  this  dictum  is  easily  demonstrated  by 
the  fact  that  it  is  almost  impossible  to  stain  living  tissue,  while 
dead  tissue  is  at  once  penetrated  by  a  suitable  staining  solution. 
Contact  anesthesia  is  possible  only  when  the  medicament  is  placed 
on  dentin  in  the  form  of  a  solution,  and  consequently  dehydration 
of  the  protoplasm  increases  the  endosmosis  of  the  anesthetic  solu- 
tion markedly. 

When  we  apply  the  same  pressure  anesthesia  on  carious  dentin, 
the  above  statements  do  not  hold  good.  We  are  able  to  press 
fluids  quite  readily  through  carious  dentin.  We  must  bear  in 
mind  that  such  dentin  has  been  largely  deprived  of  its  inorganic 


1  Walkhoff :  Das  Sensibile  Dentin,  1899. 


572  LOCAL   ANESTHESIA 

salts,  leaving  an  elastic,  spongy  matrix  in  position.  The  carti- 
laginous dentin  should  be  suitably  prepared  prior  to  the  intro- 
duction of  the  anesthetic  solution — that  is,  the  fatty  deposits  should 
be  removed  with  chloroform,  or  still  better,  with  aceton,  and  the 
moisture  dehydrated  with  the  hot  air  blast.  If  the  anesthetic  fluid 
is  now  confined  under  a  suitable  water-tight  cover,  the  pressure 
applied  by  the  finger  or  with  an  instrument  is  quite  sufficient  to 
obtain  the  desired  result.  Aqueous  eosin  solutions  may  be  forced 
through  such  dentin  in  less  than  two  minutes,  and  even  thick 
layers  of  dentin  may  be  readily  penetrated  by  such  colored  solu- 
tions by  slightly  increasing  and  prolonging  the  pressure.  It  should 
be  borne  in  mind  that  these  experiments,  if  conducted  with  teeth 
out  of  the  mouth,  do  not  at  all  represent  the  conditions  as  found 
in  teeth  in  their  normal  anatomic  surroundings. 

In  teeth  not  fully  calcified  and  in  so-called  "soft"  teeth,  pressure 
anesthesia  is  more  readily  obtained,  while,  according  to  Zeder- 
baum,^  the  process  fails  in  teeth  of  old  persons,  teeth  of  inveterate 
tobacco  chewers,  worn,  abraded,  and  eroded  teeth  with  extensive 
secondary  calcific  deposits,  teeth  whose  pulp  canals  are  obstructed 
by  pulp  nodules,  teeth  with  metallic  oxids  in  tubules,  teeth  with 
leaky  old  fillings,  badly  calcified  teeth,  mainly  all  from  one  and 
the  same  cause — namely,  clogged  tubules.  In  most  cases  no 
amount  of  persistent  pressure  will  prove  successful.  The  recent 
classic  researches  of  Reich'  on  the  formation  of  irregular  dentin 
have  amply  demonstrated  that  secondary  deposits  of  dentin  are 
much  more  frequently  present  in  the  pulp  chamber  than  have 
hitherto  been  supposed.  The  histologic  structure  of  secondary 
dentin,  as  observ^ed  under  the  microscope,  frequently  shows  an 
irregular  mass  of  twisted  tubules,  which  have  no  connection  with 
the  odontoblasts.  Such  dentin,  as  well  as  the  presence  of  pulp 
nodules,  mechanically  bars  the  forcible  introduction  of  fluids  into 
the  pulp. 

According  to  Hertwig'  the  protoplasm  of  the  cell  primarily 
transfers  irritation,  and,  secondly,  transmits  absorbed  materials, 
and  therefore  the  anesthetic  solution  has  to  pass  through  the  en- 
tire length  of  the  dentinal  fiber  before  the  nerve  tissue  of  the  pulp 


^Zederbaum:  Dental   Register,   1904,  p.  80. 
*  Reich:  Das  Irregulare  Dentin,  1907. 
•Hertwiit:      The    Cell,    1903. 


TECHNIQUE   OF   THE  INJECTION  573 

proper  is  reached.  Consequently  a  certain  period  of  time  is  re- 
quired before  the  physiologic  effect  of  the  anesthetic  is  manifested, 
and  this  period  of  latency  is  dependent  on  the  thickness  of  the  in- 
termediate layer  of  dentin  or  bone.  The  successful  anesthetization 
of  the  pulp  depends  largely  on  this  most  important  factor  of  allow- 
ing sufficient  time  for  the  proper  migration  of  the  drug. 

Immediate  root  filling  following  the  extirpation  of  the  pulp  by 
cocain  anesthesia  is  not  to  be  recommended.  Among  the  many 
good  reasons  why  a  root  canal  should  not  be  filled  at  this  sitting, 
the  following  may  be  mentioned:  The  tissues  above  the  foramen 
may  have  become  anesthetized,  and  they  do  not  act  as  a  guide 
when  the  root  is  to  be  thoroughly  filled;  the  tearing  of  the  pulp 
from  its  connections  at  the  apex  produces  more  or  less  severe  ir- 
ritation, which  can  be  readjusted  only  by  time;  the  root  filling 
coming  in  contact  therewith  will  only  further  irritate  these  tis- 
sues; and  consequently  hemorrhage  and  the  formation  of  a  clot 
in  the  apical  area  may  also  cause  future  severe  irritation  if  the 
root  is  filled  at  the  same  sitting.  A  bland  antiseptic  should  be  in- 
serted in  the  root  canal  for  a  day  or  two,  or  until  the  much  dam- 
aged tissues  about  the  apex  of  the  tooth  have  regained  their  normal 
equilibrium. 

Within  recent  years  a  number  of  complicated  syringes,  variously 
known  as  high  pressure  syringes  and  obtunders,  have  been  advo- 
cated for  the  purpose  of  forcing  anesthetic  solutions  through  tooth 
substance  by  intense  pressure.  As  we  have  stated,  this  conception 
of  pressure  anesthesia  is  erroneous.  Close  contact  of  the  anes- 
thetizing fluid  with  the  dentinal  fibers,  plus  the  necessary  time  for 
conveying  the  absorbed  anesthetic  to  the  nerve  endings,  explains 
the  phenomenon  very  plausibly.  A  strong  metal  syringe,  provided 
with  a  specially  prepared  needle  to  make  a  watertight  joint  as  near 
as  possible,  is  all  that  is  required.  Those  who  prefer  a  special 
high  pressure  syringe  for  such  purposes  may  purchase  any  one  of 
the  many  devices  that  will  best  suit  their  fancy.  The  Weaver  ob- 
tunder  or  the  Jewett-Willcox  syringe  are  much  lauded  for  such 
purposes. 

Any  of  the  various  methods  for  anesthetizing  a  tooth  for  the 
purpose  of  its  extraction,  as  outlined  under  "The  Technique  of 
the  Injection,"  may  be  used  for  anesthetizing  the  pulp.     Under 


574  LOCAL.   ANESTHESIA 

certain  conditions  such  procedures  may  be  preferred  to  the  various 
methods  of  pressure  anesthesia. 

Treatment  of  Hypersensitive  Dentin. 

Normal  dentin  has  no  sensation.  The  prolongations  of  the 
odontoblasts — the  dentinal  fibrils — when  irritated  directly  or  in- 
directly, may  become  extremely  hypersensitive.  This  condition 
lasts  as  long  as  the  pulp  remains  in  a  state  of  irritation.  The 
remedies  that  are  employed  for  the  purpose  of  relieving  the  irrita- 
tion may  be  conveniently  divided  as  follows: 

1.  General  sedatives  and  anesthetics. 

2.  Local  sedatives  and  anesthetics. 

3.  Caustics. 

The  general  sedatives  and  anesthetics  are  administered  internally 
with  the  object  of  reducing  the  sensibility  of  the  entire  nervous 
system.  Such  drugs  are  opium,  chloral  hydrate,  the  bromids, 
and  the  general  anesthetics.  The  local  sedatives  and  anesthetics 
are  applied  on  the  dentin  or  on  or  in  the  tissues  surrounding  the 
tooth.  The  object  of  the  latter  method  is  to  reach  the  nerves  at 
the  apical  end  of  the  tooth,  and  the  drugs  used  for  this  purpose 
are  cocain  and  its  substitutes,  certain  essential  oils,  and  the  re- 
frigerant agents.  The  caustics  are  applied  locally,  and  destroj^ 
the  dentinal  fibrils  progressively.  Most  caustics  are  more  or  less 
self-limiting,  and  must  be  brought  into  intimate  contact  with  the 
fibrils  in  order  to  destroy  them.  Arsenic  trioxid,  which,  correctly 
speaking,  is  not  a  caustic,  and  formaldehyd  (paraform),  are  not 
self-limiting  in  their  action,  and  when  applied  on  dentin  always 
destroy  the  pulp  via  the  dentinal  fibrils.  At  present  these  agents 
are  not  used  for  the  purpose  of  reducing  hypersensitiveness  of 
the  teeth.     (See  Buckley's  desensitizing  paste,  p.  167.) 

Without  entering  into  a  discussion  of  the  value  of  the  various 
methods  employed,  we  "wash  to  merely  call  attention  to  the  local 
anesthetization  of  the  pulp,  either  through  the  dentinal  fibrils  or 
by  way  of  reaching  the  nerves  at  the  apex  of  the  individual 
tooth.  To  desensitize  the  dentin,  any  of  the  various  methods  that 
have  been  discussed  under  "The  Technique  of  the  Injection,"  in- 
cluding pressure  anesthesia,  may  be  successfully  employed.  It 
should  be  remembered  that  the  tooth  pulp  is  practically  a  transi- 
tory organ,  which  is  subject  to  many  changes  during  its  life.     In 


TECHNIQUE   OF    THE   INJECTION  575 

the  young  the  pulp  mass  is  large  and  very  vascular,  while  in  the 
old  it  is  usually  atrophied  and  studded  with  pulp  stones  or  lime 
concretions  of  various  shapes.  It  should  be  kept  in  mind  that 
only  a  few  drops  of  a  2  per  cent  novocain-epinephrin  solution  are 
required  to  completely  anesthetize  the  pulp,  provided  sufficient 
time  be  allowed  for  the  action  of  the  anesthetic,  and  the  anesthesia 
lasts  from  forty  to  sixty  minutes.  The  objections  made  to  this 
method  that  the  pulp  may  die,  or  otherwise  become  injured  by 
the  anesthetic,  are  unfounded,  provided  the  minimum  quantity  of 
the  anesthetic  solution  is  used.  We  have  been  able  to  satisfac- 
torily demonstrate  by  tests  made  with  the  electric  current,  that 
the  pulp  always  regained  its  normal  activity  after  it  had  been 
anesthetized  for  the  above  purpose.  Recently  exhaustive  tests 
have  been  made  on  animals  by  Euler,  with  a  view  to  establishing 
the  possibility  of  producing  death  of  the  tooth  pulp  by  injecting 
novocain-epinephrin  according  to  the  above  method.  In  no  case 
did  he  succeed  in  permanently  injuring  the  pulp  even  by  em- 
ploying relatively  large  quantities  of  the  above  solution.  Acci- 
dentally cutting  into  the  pulp  in  preparing  the  cavity  may  be 
considered  a  source  of  danger,  as  the  normal  sensation  of  the 
pulp,  w^hich  acts  as  a  warning  guide  when  too  closely  encroached 
upon,  is  temporarily  abolished,  and  this  fact  may  mislead  the 
operator  when  excavating  a  cavity.  Careful  observation  of  the 
field  of  operation  will  cause  a  halt  when  the  danger  line  is  ap- 
proached. 

Some  years  ago  potassocoin,  a  solution  of  cocain  in  alcohol  and 
ether,  with  the  addition  of  a  small  quantity  of  caustic  potash,  and 
vnpocain,  "a.  local  obtundent  containing  15  per  cent  cocain  hydro- 
ehlorid  in  ethereal  solution,"  were  freely  discussed  in  dental  litera- 
ture as  useful  remedies  for  the  treatment  of  hypersensitive  dentin. 
Both  solutions  are  active  only  through  their  cocain  component. 
The  latter  is  materially  interfered  with  in  its  ready  absorption  by 
the  alcohol  or  ether  solvent.  Potassocoin  apparently  disappeared 
from  the  market,  while  vapocain  is  seemingly  still  in  use.  When 
applied  to  dentin,  the  ether  has  to  be  evaporated  before  the  cocain 
can  act  on  the  dentinal  fibers,  and  has  to  be  redissolved  by  the 
aqueous  contents  of  the  tubules  in  order  to  act.  "Vapocain  is 
found  in  practice  to  possess  great  penetrating  power,  and  this  ac- 
tion seems  to  be  due  to  the  fact  that  the  heat  of  the  mouth  vapor- 


576  LOCAL   ANESTHESIA 

izes  a  portion  of  the  ether,  driving  the  natural  fluid  of  the  tooth 
out  of  the  tubules,  thus  securing  a  rapid  distribution  of  the  re- 
maining portion  throughout  the  tooth  structure.  From  this  por- 
tion the  ether  is  dissipated,  leaving  the  cocain  salt  distributed  in 
minute  subdivisions  throughout  the  tubules.  The  cocain  is  then 
redissolved  by  the  natural  fluid  of  the  tooth,  securing  a  rapid 
and  effective  anesthesia."  Under  pressure  anesthesia  we  have 
discussed  the  fallacy  of  ''driving  cocain  into  the  tubules  of  a  liv- 
ing tooth." 

Some  years  ago  cataphoresis  was  much  lauded  for  the  purpose 
of  densitizing  dentin.  The  principle  of  cataphoresis — electric  en- 
dosmosis — consists  in  carrying  a  drug,  which  must  be  an  electro- 
lyte, by  means  of  the  electric  current  into  the  tissues.  The  medic- 
ament is  decomposed  by  the  current — electrolysis — into  ions. 
The  ion,  which  is  deposited  on  the  positive  pole,  is  known  as  the 
anion,  and  the  deposit  on  the  negative  pole  is  referred  to  as  the 
kation.  For  the  above  purposes  cocain  is  usually  employed.  The 
complicated  apparatus  and  the  many  difficulties  that  are  encoun- 
tered in  the  application  of  cataphoresis  do  not  justify  the  results 
obtained,  as  they  are  often  unsatisfactory,  and  the  method  has  been 
generally  abandoned.  From  an  historical  point  of  view  it  is  in- 
teresting to  observe  that  Keuss,^  of  Moscow,  wrote  as  early  as  1809 
on  the  subject  of  electric  endosmosis.  He  was  followed  in  later 
years  by  a  number  of  other  investigators,  especially  by  Wiedemann 
(1856),  Du  Bois-Reymond  (1860),  Clemens  (1860),  and  Beer 
(1869).  When  cataphoresis  was  introduced  into  dentistry  in  1895 
it  seems  that  the  past  literature  on  the  subject  had  escaped  the 
notice  of  the  majority  of  the  writers  on  this  subject,  and  many  of 
the  known  facts  had  to  be  "rediscovered." 

Local  Anesthesia  for  Operations  About  the  Mouth,  Exclusive 
of  the  Extraction  of  Teeth. 

In  operating  about  the  mouth  for  an  abscess,  a  cystic  or  a  solid 
tumor  of  the  approximate  size  of  a  large  walnut,  a  malposed  tooth, 
or  for  any  other  purpose,  the  rhomboid  infiltration  according  to 
Hackenbruch^  affords  the  simplest  methods  of  producing  a  most 

*  Reuss:  Notice  sur  un  Nouvel  EflEect  de  1'  filectricite  Galvanique.  Memoirs  de  la 
Societe  Imperiale  des  Naturalistes  a  Moscou,  Vol.  II. 

'  Hackenbruch:    Schmerzverhutung  in   der   Chirurgie,    1906. 


TECHNIQUE   OP    THE   INJECTION  577 

satisfactory  anesthesia.  After  previously  cleansing  the  field  of 
operation  with  an  antiseptic  solution,  a  very  small  drop  of  phenol 
is  placed  at  a  and  &  (Fig.  157)  to  superficially  obtund  the  point 
of  puncture.  The  needle  is  quickly  thrust  through  the  mucosa  at 
a,  and  at  once  slow  pressure  is  exerted  on  the  piston,  moving  the 
needle  steadily  along  the  external  line  of  the  tumor.  The  needle 
is  now  partially  withdrawn,  without,  however,  leaving  the  origi- 
nal puncture,  and  a  second  injection  or  as  many  as  may  be  needed 
are  made  in  opposite  directions.  This  maneuver  is  now  repeated 
at  h,  and  thus  a  circumscribed  infiltration  of  the  whole  tumor  is 
obtained.  If  the  tumor,  etc.,  is  very  large,  additional  punctures 
and  injections  may  be  made  as  outlined  in  the  schematic  draw- 
ing.    After  ten  to  fifteen  minutes'  waiting  the  extirpation  of  the 


Fig.   157. 
Anesthetizing  a  small   tumor  by  rhomboid  injection.      (Ilackenbruch.) 

tumor  may  be  begun.  For  injecting  the  soft  tissues  other  than 
the  gum,  a  1  per  cent  novocain-epinephrin  solution  is  quite  suffi- 
cient. 

The  anesthetization  of  the  soft  and  hard  palate  is  comparatively 
easily  accomplished.  The  injection  on  the  hard  palate  is  started 
at  the  gingival  edge  of  the  alveolar  periosteum  on  both  sides  of 
the  jaw  toward  the  median  line.  As  this  gum  tissue  is  extremely 
dense,  great  force  is  required  for  a  complete  infiltration  in  this 
region,  and  only  small  quantities  of  the  solution  are  required. 
The  soft  palate  is  easily  infiltrated  by  inserting  the  curved  needle 
posteriorly  of  the  third  molar. 

Small  tumors  and  cysts  on  the  tongue  or  the  floor  of  the  mouth 
are  best  anesthetized  by  the  rhomboid  infiltration  of  Hackenbruch. 


578  LOCAL   ANESTHESIA 

For  the  complete  extirpation  of  a  ranula,  the  injection  is  made 
into  the  cyst  wall  near  the  periphery,  after  which  the  cyst  is  slit 
open  and  a  small  quantity  of  the  anesthetic  solution  is  injected 
into  the  inner  surface  of  the  cyst.  Large  cysts,  tumors,  and  major 
operations  on  the  tongue  require  the  anesthetization  of  both  lin- 
gual nerves,  as  described  on  page  533.  In  injecting  and  operat- 
ing on  the  floor  of  the  mouth,  the  index  finger  of  the  left  hand 
should  be  placed  on  its  external  surface  as  a  guide  to  the  needle 
or  the  knife. 

The  opening  of  the  maxillary  sinus  (antrum  of  Highmore) 
from  the  oral  cavity,  whether  by  the  Cowper-Drake  operation — 
through  the  alveolus  of  an  extracted  tooth — or  by  the  Lamorier- 
Desault  modification — through  the  canine  fossa — is  successfully 
accomplished    under   local    anesthesia.      If   the    sinus    is    opened 


Fig.   158. 
Section  through  an  anesthetized  tumor,     a,  b,  the  zone  of  infiltration.     (Hackenbruch.) 

through  an  alveolus,  the  technique  of  the  injection  is  practically 
the  same  as  used  for  the  extraction  of  a  tooth.  If  the  perfora- 
tion is  to  be  made  through  the  anterior  wall  of  the  sinus,  the  in- 
filtration of  the  tissues  is  made  as  follows:  The  corner  of  the 
mouth  is  lifted  upward  and  backward  by  means  of  a  cheek  re- 
tractor, the  injection  is  started  by  inserting  the  needle  horizon- 
tally over  the  canine  tooth  near  the  gum  fold  and  in  close  con- 
tact with  the  bone,  and  the  needle  is  m,oved  posteriorly  in  various 
directions  so  as  to  infiltrate  as  large  a  field  as  possible.  A  sec- 
ond injection  is  made  near  the  infra-orbital  foramen.  Two  to 
three  cubic  centimeters  of  the  anesthetic  solution  are  necessary. 
After  ten  minutes '  waiting  a  large  semi-circular  cut  is  made,  reach- 
ing from  the  canine  eminence  to  the  first  molar;  the  flap,  includ- 
ing the  periosteum,  is  lifted  up,  and  the  extremely  thin  bone  is 
now  penetrated  with  a  suitable  drill.  The  sensitive  mucous  lining 
of  the  sinus  is  usually  sufficiently  anesthetized  by  the  penetration 
of  the  fluid  through  the  thin  bone.  "We  can  recommend  this  method 
of  opening  the  antrum  of  Highmore  as  the  most  satisfactory  pro- 
cedure from  the  dental  surgeon's  standpoint. 


AFTER  EFFECTS  OF  LOCAL  ANESTHETICS  579 

SIDE  AND  AFTER  EFFECTS  OF  LOCAL  ANESTHETICS  AND 
THEIR  RELATION  TO  THE  PENAL  CODE. 

Since  cocaiii  and  its  many  substitutes,  employed  for  the  pur- 
pose of  producing  local  anesthesia,  have  become  an  important  ad- 
junct to  the  armamentarium  of  a  routine  practice,  quite  a  num- 
ber of  eases  are  on  record  in  which  the  administration  of  these 
chemicals  has  caused  serious  untoward  effects,  which  resulted  in 
bringing  the  respective  practitioners  in  conflict  with  the  law. 
From  a  legal  point  of  view  these  side  and  after  effects  may  be 
considered  as  resulting  in  death  of  the  patient,  or  producing  in- 
tense psychic  disturbances.  Deaths  from  cocain,  administered  hy- 
podermically,  were  comparatively  frequent  in  the  earlier  days  of 
its  history,  and  may  be  attributed  to  two  specific  causes — first,  to 
an  impure  product,  and,  second,  to  a  too  large  dose. 

Cocain  intoxication  usually  manifests  itself  in  three  definite 
ways.  The  first  stage  is  characterized  by  intense  psychic  excite- 
ment; violent  incoherent  gesticulations  are  predominant,  which 
are  accompanied  by  muscular  tremors  and  garrulity;  the  pulse  is. 
rapid  and  the  respiration  is  very  much  increased ;  frequently  pro- 
nounced depressing  sensations  are  noticed ;  very  slowly  the  patient 
will  become  quiet  again.  The  second  form  of  intoxication  is  rela- 
tively seldom  met  with;  clonic  and  tonic  spasms  of  groups  of 
muscles,  especially  of  the  arms  and  limbs,  are  predominant;  oc- 
casionally complete  spasms  may  occur;  after  diminishing  of  the 
disturbance,  the  patient  falls  into  a  deep  sleep.  The  third  and 
m,ost  common  form  of  cocain  intoxication  is  the  so-called  cocain 
collapse ;  the  patient  faints ;  the  skin  is  cold  and  clammy ;  the 
pulse  is  low,  very  rapid,  and  sometimes  irregular;  the  respiration 
is  much  increased,  being  laborious  in  the  beginning  and  later  on 
weaker  and  irregular,  resembling  what  is  known  as  the  Cheyne- 
Stokes  respiration ;  there  is  a  pronounced  feeling  of  fear  from  suf- 
focation and  heart  weakness;  the  patient  collapses  into  a  deep 
coma,  and  death  results  from  cessation  of  respiration. 

Lewin^  cites  some  very  interesting  factors  concerning  the  side 
action  of  cocain.  He  states  that  neither  the  dose,  the  point  of  ap- 
plication, nor  the  individuality  plays  an  important  part  in  the 


»Lewin:  Nebenwirkungen  der  Arzneimittel,   1899. 


580  LOCAL   ANESTHESIA 

untoward  effects  of  cocain.  These  disturbances  may  occur  either 
within  a  few  minutes  or  even  months  after  the  administration  of 
the  poison.  Cases  are  on  record  which  show  that  patients  have 
suffered  for  several  weeks,  or  even  for  months,  from  its  side  effects. 
Women  who  have  received  cocain  may  display  erotic  conditions, 
with  or  without  disturbance  of  consciousness.  This  fact  makes  it 
apparent  that  it  is  advisable  to  have  a  third  person  present  when 
cocain  is  to  be  administered  by  the  practitioner.  In  one  instance 
the  injection  of  cocain  produced  voluptuous  emotions  in  a  man, 
which  resulted  in  ejaculation,  and  thus  became  the  primary  cause 
of  his  becoming  a  cocain  habitue.  The  disturbances  of  the  central 
nervous  system  manifest  themselves  in  more  or  less  intense  excite- 
ment, either  temporarily  or  lasting  for  hours,  or  even  weeks.  The 
patient  is  usually  very  garrulous  or  hilarious;  he  will  boast  of 
his  great  corporal  strength  and  his  immense  mental  faculties;  he 
may  remember  facts  which  occurred  twenty  or  thirty  years  ago, 
or  he  may  talk  in  a  quivering  voice,  or  show  signs  of  slight  in- 
toxication ;  often  he  runs  to  and  fro,  moving  his  arms  or  his  body 
violently,  or  gives  signs  of  hallucinations;  occasionally  the  excite- 
ment may  become  so  intense  as  to  resemble  mania.  The  paroxysm 
of  inten'se  excitement  is  usually  followed  by  a  more  or  less  last- 
ing depression,  which  often  reaches  a  melancholic  or  apathetic 
state. 

Intense  psychic  disturbances  from  average  doses  of  cocain  and 
its  substitutes  are  comparatively  rare  at  present,  but  nevertheless 
the  recorded  cases  that  have  found  their  final  settlement  in  courts 
of  law  are  of  sufficient  importance  to  the  general  practitioner  to 
warrant  special  mention.  While  it  is  an  established  fact  that  af- 
ter general  narcosis — whether  the  anesthetic  be  chloroform,  ether. 
ethyl  chlorid,  ethyl  bromid,  nitrous  oxid,  etc. — erotic  dreams 
and  sexual  excitement  have  been  frequently  observed  in  men,  and 
more  especially  in  w^omen,  it  is  also  important  to  remember  that 
such  disturbances  do  occur  after  the  injection  of  local  anesthetics. 
Cocain  and  its  substitutes  do  not  produce  general  narcosis,  but 
they  are  known  to  have  brought  about  a  form  of  semi-conscious 
sleep,  which  apparently  resembles  hypnotic  sleep.  Fischer^  re- 
ports a  case  of  this  nature  as  follows: 

A  lady  about  36  years  of  age,  well  built  and  of  sound  health, 


*  Fischer:  Deutsche  Zahnarztliche  Wochenschrift,  1908,  p.  545. 


AFTER   EFFECTS    OF    LOCAL   ANESTHETICS  581 

wished  to  have  the  abscessed  roots  of  a  lower  molar  extracted. 
Fischer  injected  3  cubic  centimeters  of  a  2  per  cent  novocain- 
thymol  solution,  to  which  he  had  added  at  the  time  of  the  injec- 
tion 3  drops  of  the  new  synthetic  suprarenin  solution  (Hochst), 
1 :1000.  The  injection,  as  in  all  patients  of  good  constitution,  was 
completed  without  pain.  The  time  necessary  for  the  diffusion  of 
the  liquid  through  the  lower  jaw  bone  was  approximately  calcu- 
lated at  fifteen  minutes.  To  make  use  of  the  intervening  time, 
Fischer  excavated  two  cavities  on  the  same  side  of  the  mouth  in 
the  upper  jaw.  About  one  minute  after  the  injection  the  patient 
noticed  a  complete  anesthesia  of  the  entire  half  of  the  left  lower 
jaw;  after  about  five  minutes  she  was  unable  to  feel  the  touch 
of  the  drinking  glass  on  the  lips  on  the  affected  side,  and  at  about 
this  time  a  slight  increase  in  the  pulse  rate,  lasting  from  one  to 
three  minutes,  was  perceptible.  The  patient  fell  into  a  half  slum- 
ber, and  she  was  barely  able  to  open  the  mouth  sufficiently  to 
allow  the  preparation  of  the  cavities  in  the  upper  teeth.  The 
pulse  and  the  respiration  were  soon  normal  again,  and  the  patient 
had  the  appearance  of  a  peaceful  sleeper.  She  opened  and  closed 
her  mouth  at  the  doctor's  command,  and  followed  instructions, 
without,  however,  opening  her  eyes.  The  cavities  were  excavated 
without  apparently  feeling  any  pain,  although  the  pulps  were 
nearly  exposed.  About  twenty  minutes  may  have  elapsed,  and  the 
two  badly  decayed  root  remnants  were  extracted.  The  patient 
awoke  with  a  start,  opened  her  eyes,  and  at  the  doctor's  command 
washed  out  her  mouth.  She  was  now  perfectly  normal,  and  stated 
that  a  sudden  pain  from  pressure  awakened  her.  The  anesthesia 
on  the  left  side  of  the  mouth  was  still  persistent.  The  patient 
claimed  that  she  always  had  been  perfectly  sound  and  healtliy, 
and  that  she  reacted  very  quickly  and  strongly  to  medicines.  She 
had  no  knowledge  of  what  happened  during  the  sleep,  and  she 
was  glad  to  know  that  the  teeth  were  filled  and  the  roots  extracted 
Another  interesting  case  that  illustrates  very  forcibly  the  pro- 
nounced psychic  effects  of  local  anesthetics,  resulting  in  this  in- 
stance in  grave  charges  against  the  attending  dental  surgeon,  oc- 
curred in  Korner's^  dental  clinic  at  the  University  of  Halle  (Ger- 
many). The  wife  of  a  school  teacher  presented  herself  at  the  in- 
firmary to  have  a  root  of  a  bicuspid  extracted.     The  tissues  were 


'  Korner:  Deutsche  Monafssclirift  fiir  Zahnlieilkunde,   1904,  p.  283. 


582  LOCAL   ANESTHEGIA 

locally  anesthetized  with  the  ethyl  chlorid  spray,  and  the  root 
was  extracted  by  a  student  in  the  presence  of  the  instructor. 
Not  the  slightest  indication  of  a  general  narcosis,  as  sometimes  oc- 
curs by  inhaling  the  vapors  of  ethyl  chlorid  when  sprayed  on  tis- 
sues in  the  mouth,  was  noticed.  Immediately  after  the  tooth  was 
removed  the  woman  left  the  operating  room,  being  instructed  to 
return  in  a  week's  time  to  have  her  mouth  inspected.  A  week 
later  the  woman  appeared  before  the  chief  of  police,  and  in  the 
presence  of  a  physician  made  the  statement  that  she  had  been 
raped  by  both  the  instructor  and  the  student  at  a  dental  institu- 
tion. The  recalling  of  this  supposed  episode  occurred  to  her  a  week 
after  the  operation  at  the  very  moment  when  she  re-entered  the 
dental  infirmary.  Korner  at  once  demanded  a  medical  examina- 
tion of  the  woman,  and  the  neurologists  diagnosed  an  acute  psy- 
chotic disturbance,  which  resulted  in  committing  her  to  an  insane 
asylum,  from  which,  after  months  of  treatment,  she  was  discharged. 

Hallucinations  produced  under  cocain  influence  may  result  in 
definite  lasting  impressions  regarding  certain  persons  or  circum- 
stances.    The  follo^ving  case  furnishes  a  definite  illustration  :^ 

A  young  lady  claimed  that  she  had  been  grossly  insulted  in  a 
dental  institute  in  Vienna,  and  that  she  recognized  in  the  person 
of  Doctor  X,  the  supervisor  of  the  clinic,  her  assailant.  Her  testi- 
m,ony  consisted  in  one  stereotyped  answer  to  all  questions,  "It  is 
he."  On  this  testimony,  and  in  spite  of  the  Doctor's  plea  that 
he  had  never  seen  the  person  before,  the  Doctor  was  sentenced  to 
serve  eight  days  in  jail.  The  defense  appealed  the  case  for  re- 
vision, and  Doctor  X  introduced  a  few  snapshot  pictures  that  were 
made  with  a  camera  by  some  friends  while  they  and  he  were  on 
a  visit  some  miles  away  from  Vienna  on  the  same  day  and  at  the 
same  hour  which  the  plaintiff  had  specified  in  her  claim.  On 
being  confronted  with  the  pictures,  the  Avoman  again  pointed  to 
the  Doctor's  figure  in  the  picture  and  exclaimed,  "It  is  he."  The 
Court  thereupon  dismissed  the  case. 

Cocain  intoxication,  when  combined  with  hysteria,  may  in  some 
instance  place  the  operator  in  an  extremely  embarrassing  posi- 
tion, as  illustrated  in  the  following  case:'' 

A  miss  had  a  tooth  extracted  at  a  dental  clinic,  a  local  anesthetic 


>  Ritter:  Berliner  Zahnarztliche   Halbmonatsschrift,    1908,    Vol.    XVIIL 
'Ritter:  Rechte,  Pflichten  und  Kunstfehler  in  der  Zahnheilkundc,  1903. 


AFTER   EFFECTS   OF   LOCAL   ANESTHETICS  583 

being  used.  She  showed  signs  of  slight  coeain  intoxication  and 
hysteric  disturbances,  but  soon  rallied  and  went  home.  Shortly 
afterward  the  assistant  of  the  clinic,  who  was  present  at  the  opera- 
tion, but  whom  the  lady  did  not  know  even  by  name,  received 
love  letters  from  her.  They  remained  unanswered,  and  three  days 
later  the  lady  killed  herself  by  shooting  after  she  had  written  to 
the  assistant  that  she  would  do  so  unless  she  received  an  answer 
from  him. 

To  illustrate  the  temporary  paralyzing  effect  of  coeain  intoxica- 
tion, the  following  case  will  serve  as  an  example  :^ 

On  the  29th  day  of  August,  1888,  a  woman  went  into  the  office 
of  Doctor  E.  P.  Maloney,  of  New  Orleans,  to  have  a  tooth  ex- 
tracted. In  order  to  extract  it  without  pain,  the  doctor  injected 
coeain  hypodermically,  in  accordance  with  the  demand.  She 
stated  that  she  had  had  the  drug  administered  previously,  and 
that  she  was  keenly  sensible  to  its  effects,  the  last  operation  having 
rendered  her  ill  for  nearly  three  weeks.  With  these  facts  as  a 
guide.  Doctor  Maloney  proceeded  to  inject  a  small  quantity  of  a 
weak  solution— 2  per  cent— into  the  gums.  The  lady  demanded 
that  more  of  the  drug  be  used,  as  the  gums  still  ached,  and  when 
the  doctor  demurred  she  left  the  chair  without  the  tooth  having 
been  extracted.  At  the  time  she  left  she  felt  ill,  and  a  moment 
later,  after  she  had  passed  out  of  the  office  into  the  hall,  the  Doctor 
was  startled  at  hearing  a  piercing  scream  coming  from  that  direc- 
tion, and,  hastily  going  to  the  spot,  found  that  the  lady  had  fallen 
unconscious.  She  remained  in  that  condition  for  several  hours, 
and  ten  thousand  dollars  damages  were  demanded  for  the  injuries 
sustained  from  the  injection  of  coeain.  The  case  was  thrown  out 
of  court  on  a  technical  error. 

The  defense  of  a  charge  of  assault  claimed  to  have  been  com- 
mitted while  the  patient  was  under  the  influence  of  local  anes- 
thesia requires  the  careful  consideration  of  certain  important  fac- 
tors. Judge  and  jury  are  seldom  confronted  with  cases  of  this 
nature,  and  they  are  only  too  apt  to  place  the  guilt  on  the  dentist, 
especially  if  he  is  a  young  practitioner  and  is  unable  to  bring  wit- 
nesses for  his  defense.  If  the  plaintiff  is  a  young  miss,  the  chances 
are  still  worse  for  the  practitioner. 


'  Rehfuss:   Dental  Jurisprudence,   1892,  p.  65. 


584  LOCAL   ANESTHESIA 

From  a  medical  point  of  view  the  strong  plea  of  the  defense 
should  center  about  the  following  facts  :^ 

1.  Cocain  and  most  likely  its  alkaloid  and  synthetic  substi- 
tutes employed  as  local  anesthetics  are  known  to  produce  more 
or  less  intense  side  and  after  effects,  which  may  result  in  severe 
psychic  disturbances. 

2.  The  local  uses  of  cocain  and  its  substitutes  do  not  produce 
general  narcosis.  They  are  known  to  have  induced  sexual  excite- 
ment and  erotic  disturbances,  which  are  prone  to  appear  more 
often  in  woman  than  in  man. 

3.  Local  anesthesia,  as  produced  in  the  mouth  by  ethyl  chlorid 
or  similar  hydrocarbons,  may  also  produce  light  forms  of  general 
anesthesia  if  some  of  the  vapor  is  inhaled. 

Frequently  a  well-prepared  brief,  setting  forth  the  side  and 
after  effects  of  local  anesthetics,  including  an  index  of  the  litera- 
ture on  the  subject,  and  placed  in  the  hands  of  the  presiding  judge, 
may  materially  assist  in  bringing  about  a  broader  conception  of 
the  case  under  consideration. 


»Dorn:   Odontologische   Blatter,    1906,   p.    223. 


APPENDIX 

DIAGNOSIS  OF  DISEASES  OF  THE  PULP  BY  THE 
ELECTRIC  CURRENT. 

When  a  weak  electric  current  is  passed  through  the  body  of  a 
vital  tooth,  a  more  or  less  pronounced  reaction  is  produced,  which 
is  an  expression  of  the  vitality  of  its  pulp.  By  carefully  gauging 
the  current,  the  resulting  irritation  expressed  as  pain  becomes 
a  most  valuable  diagnostic  agent  in  determining  the  stage  of  vi- 
tality of  the  pulp.  The  correct  diagnosis  of  a  normal,  a  diseased, 
or  a  dead  pulp  is  always  a  matter  of  great  difficulty,  and  this 
difficulty  is  proportionally  increased  if  the  tooth  under  considera- 
tion does  not  present  any  visible  signs  of  derangement.  Various 
physical  tests — color,  translueency,  conductivity  of  temperature, 
percussion  sound,  etc. — are  at  present  in  vogue,  either  alone  or 
in  their  combined  forms.  The  diagnostic  value  of  these  various 
tests  is,  to  some  extent  at  least,  helpful  in  arriving  at  some  pos- 
sible diagnosis,  but  these  tests  furnish  no  positive  proof  of  the  con- 
dition of  the  pulp.  The  transparency  of  the  tooth  may  not  be 
altered  perceptibly  by  the  death  of  the  pulp.  The  discoloration 
of  a  tooth,  on  the  other  hand,  may  be  brought  about  by  the  va- 
rious filling  materials  themselves,  by  recurrent  caries  under  the 
filling,  or  by  leakage  of  the  filling.  The  transillumination  of  a 
tooth  by  means  of  the  electric  mouth  lamp  furnishes  a  fairly  re- 
liable shadow  picture  of  a  healthy  pulp ;  the  picture  is  diffused 
or  dull  when  a  dead  pulp  is  present.  Owing  to  the  natural  size 
of  the  teeth,  the  anterior  teeth  are  more  easily  transillumiiiated. 
In  the  bicuspids,  and  especially  in  the  molars,  the  thick  body  of 
the  tooth  crowns  prevents  ready  transillumination,  and  as  a  con- 
sequence the  diagnostic  value  of  the  light  rays  is  much  diminished. 
Transillumination  of  the  oral  structures  should  always  be  con- 
ducted in  a  darkened  room,  as  it  will  materially  assist  in  bring- 
ing out  the  shadow  pictures  much  clearer  than  in  the  presence 

585 


586 


APPENDIX 


of  light.  The  heat  test  is  also  useful,  but  by  no  means  absolute. 
Usually  this  test  is  made  by  placing  a  pellet  of  heated  gutta- 
percha or  some  similar  material  on  the  surface  of  the  suspected 
tooth.  A  tooth  with  a  dead  pulp  does  not  respond  in  the  same 
manner  as  a  tooth  with  a  normal,  living  pulp.  The  thickness 
of  the  tooth  structure  and  the  presence  of  the  various  filling 
materials  may,  according  to  their  nature,  increase  or  decrease  the 


Fig.   159. 

Typical  small  faradic  battery,  with  induction  coil  and  core  shield.     The  battery  shows 
the  hand  electrode  and  the  dental  electrode  connected  with  the  combined  current. 


conductivity  of  heat.  An  existing  pulpitis  may  sometimes  be 
fairly  well  diagnosed  by  the  use  of  water  of  various  temperatures. 
Walkhoff  makes  the  statement  that  a  normal  pulp  will  not  re- 
act between  68°  and  120°  F.  (20°  and  50°  C).  Pain  produced 
by  water  below  98°  F.  (37°  C.)  indicates  inflammation,  while 
pain  produced  above  this  temperature  indicates  the  formation 
of  pus.     Tapping  the  tooth  with  a  steel  instrument  is  helpful. 


DIAGNOSIS   OP   DISEASES   OP   PULP   BY    ELECTRIC    CURRENT         587 

Percussion  is  best  performed  by  striking  the  tooth  with  the  butt 
end  of  an  excavator,  employing  a  short,  sharp  blow.  The  peculiar 
dullness  of  the  resulting  sound  from  a  tooth  with  a  dead  pulp,  as 
compared  with  that  from  a  normal  tooth,  can  be  distinctly  dis- 
cerned by  the  trained  ear.  The  dullness  of  the  sound  is  probably 
caused  by  inflammatory  changes  of  the  peridental  membrane  re- 
sulting from  the  disturbances  of  the  products  from  the  dead  pulp 
or  from  external  causes.     The  infiltration  and  the  thickening  of 


Fig.   160. 
Dental  electrode.     Charged  with  a  wisp  of  cotton,  ready  for  use. 

the  fibers  change  the  relationship  of  the  tooth  to  the  alveolar 
bone,  and  consequently  the  sound  waves  produced  by  the  tap- 
ping have  not  that  full,  clear  tone  which  we  perceive  from  a 
similar  percussion  of  a  tooth  with  a  normal  pulp  and  healthy  per- 
icementum. Within  recent  years  the  electric  current  has  been  ad- 
vocated as  a  means  of  diagnosing  diseases  of  the  pulp.    The  results 


Fig.   161. 
Dental  hard  rubber  electrode  with  interrupter.  ^ 

obtained  by  this  process  are  very  gratifying,  and  its  use  for  such 
purposes  deserves  to  be  highly  recommended. 

History.  In  a  remarkable  book,  "Treatise  on  Dental  Caries," 
by  Magitot^  (Paris,  1867)  and  translated  by  Chandler  (Boston, 
1878)  the  following  statement  is  recorded:  "This  examination 
(of  the  dental  system)  under  circumstances  so  obscure,  demands 
a  careful  attention.  .  .  .  Another  method  has  also  been  pro- 
posed ;  it  consists  of  causing  an  electric  current  to  pass  along  the 


»Magitot:  Treatise  on  Dental  Caries,  translated  by  T.  H.   Chandler,  Boston,  1878. 


588  APPENDIX 

whole  extent  of  the  dental  arches  by  means  of  one  of  the  little  in- 
duction apparatuses  so  frequently  employed  nowadays  in  medicine. 
By  the  passage  of  a  current  so  feeble  as  not  to  cause  of  itself  any 
pain,  the  carious  tooth  will  become  the  seat  of  an  acute  and  clearly 
localized  pain. 

John  S.  Marshall/  in  a  paper  entitled,  "Electricity  as  a  Thera- 
peutic Agent  in  the  Treatment  of  Hyperemia  and  Congestion  of 
the  Pulp  and  the  Peridental  Membrane,"  makes  the  following 
statement :  'As  a  means  of  diagnosis  in  obscure  cases  of  the  vitality 
or  nonvitality  of  the  dental  pulp,  I  know  of  nothing  so  sure  to 
demonstrate  to  a  positive  certainty  these  conditions  as  the  elec- 
trical currents,  both  the  galvanic  and  the  faradic.  In  the  more 
obscure  cases,  however,  the  faradic  is  superior  to  the  galvanic,  for 
if  there  is  the  slightest  vitality  remaining  in  the  pulp,  it  will 
demonstrate  it  instantly  by  causing  a  response  in  the  tooth."  In 
1896  Woodward^  demonstrated  the  foUo^ving:  "If  a  few  cells  of 
a  cataphoric  apparatus  are  in  action,  and  the  positive  electrode  be 
applied  to  the  dentin  or  a  metallic  filling  in  a  vital  tooth,  while 
the  negative  pole  is  at  the  cheek  or  wrist  of  the  patient,  a  distinct 
sensation  should  be  felt,  while  in  case  of  a  dead  pulp  there  will  be 
no  response;  usually  even  a  small  filling  will  transmit  a  distinct 
shock  in  a  vital  tooth,  which  is  absent  in  a  devitalized  tooth.  A 
mild  interrupted  current  has  also  been  used  for  the  test.  "^ 

Marshall's  as  well  as  "Woodward's  recommendation  of  testing 
the  pulp  by  the  electric  current  has  never  received  the  recognition 
by  the  profession  Avhich  it  justly  deserves.  In  1902  Fuyt*  pub- 
lished his  researches  "about  the  use  of  weak  interrupted  currents 
for  the  purpose  of  locating  certain  diseases  in  the  pulp."  About 
the  same  time,  but  independent  of  Fuyt,  Hafner^  utilized  the  re- 
duced direct  current  for  the  same  purpose.  A  year  before  the 
publication  of  Fuyt's  and  Hafner's  observations,  Schroder^  had 
used  the  secondary  electric  current  for  diagnosing  diseases  of  the 
tooth  pulp,  and  he  published  his  observations  in  the  annual  report 
of  his  institution  (1902),    Since  then  quite  an  extensive  amount  of 


» Marshall:  Dental  Cosmos,   1891,  p.  973. 

'Woodward:   Proceedings  Philadelphia  Academy  of  Stomatology,   1896. 

•  Inglis,   Philadelphia:    Private   communication,    1908. 
*Fuyt:  Zahnarztliche   Rundschau,    1902,   p.   533. 

'  Hafner-Schurter:    Schweizer  \'ierteljahrsschrift   fur  Zahnheilkunde,    1902,   No.   4. 

•  Schroder:   Correspondenz  Blatt  fur  Zj>hnarzte,  1905,  No.   1. 


DIAGNOSIS   OF    DISEASES   OP   PULP    BY   ELECTRIC    CURRENT         589 

literature  on  this  interesting  subject  has  appeared,  the  more  impor- 
tant publications  being  those  of  Witthaus/  Grevers,^  Hamburger,^ 
Frohmann,*  Hesse,^  An  der  Lahn,^  Schroder,''  Tousey,^  etc.  It  is 
interesting  to  note  that  the  various  observers  differ  as  far  as  the 
nature  of  the  electric  current  is  concerned.  Fuyt  advises  the  pri- 
mary current  and  Schroder  uses  the  secondary  current  of  the 
faradic  battery,  while  Hafner  advocates  the  reduced  direct  cur- 
rent. The  alternating  current  can  not  be  used  for  such  purposes. 
All  investigators,  however,  obtained  precisely  the  same  results.  To 
judge  from  the  various  publications  on  the  subject,  coupled  with 
our  observations  in  the  use  of  this  method,  the  primary  and  sec- 
ondary combined  faradic  current  is  best  suited  for  this  work  on 
account  of  the  simplicity  of  the  apparatus  and  the  easy  manner  in 
which  this  current  can  be  regulated. 

The  Faradic  Current  and  Its  Accessories. — The  faradic  bat- 
tery delivers  an  easily  controlled  current  of  minute  quantity. 
Two  forms  of  induction  coils,  in  connection  with  the  battery,  are 
in  general  use  for  this  purpose — the  induction  coil  with  a  core 
shield  (the  tube  of  Duchenne)  and  the  sledge  induction  coil  of 
Du  Boys-Reymond.  The  source  of  electricity  for  the  smaller  in- 
duction coil  is  usually  received  from  a  single  dip  battery  (acid 
potassium  bichromate  solution)  or  an  ordinary  dry  cell,^  while 
the  sledge  induction  coil  may  be  fed  from  a  series  of  batteries, 
or  from  the  street  current,  which  is  reduced  by  a  reostat.  The 
small,  transportable  induction  coil  with  one  dry  cell  battery  gives 
universal  satisfaction  for  the  purpose  in  view,  and  on  account  of 
its  cheapness,  simplicity,  and  easy  transportation  deserves  to  be 
recommended. 

The  induction  coil  produces  a  secondary  current  in  a  circuit 
placed  near  to,  but  not  in  contact  with,  the  galvanic  field.     This 


1  Witthaus:   Deutsche   Monatsschrift  fur  Zahnheilkunde,   1902,  No.   11. 

^Grevers:   Dental   Cosmos,   1903,   p.    58. 

'Hamburger:  Deutsche  Monatsschrift  fur  Zahnheilkunde,   1907,  No.  6. 

'Frohmann:    Deutsche   Monatsschrift   fiir  Zahnheilkunde,    1907,   No.    3. 

0  Hesse:   Deutsche  Monatsschrift  fur  Zahnheilkunde,   1907,   No.   3. 

•An  der  Lahn:  Osterreich-Ungarische  Vierteljahrsschrift  fiir  Zahnheilkunde,  1907, 
No.  2. 

•Schroder:   Der  Inductionsstrom  als  Diagnosticum  in  der  Zahnarztlichen   Praxis,  1907. 

'Tousey:   Dental   Cosmos,    1909,  p.   513. 

•Battery  fluid  for  the  dip  battery:  To  5  pints  of  water  add,  under  constant  stirring,  8 
fluidounces  of  sulphuric  acid  in  a  thin  stream.  Dissolve  at  once  7^  ounces  of  powdered 
|)otassium  bichromate  in  the  hot  mixture;  after  cooling,  the  fluid  is  ready  for  use. 


590  APPENDIX 

galvanic  field,  the  primary  current,  is  represented  by  three  or  four 
layers  of  coarse  copper  wire,  which  are  wound  about  the  hollow, 
nonconducting  cylinder,  and  the  two  ends  of  which  are  united 
with  the  binding  posts.  Within  the  cylinder  is  found  a  core  of 
soft  iron  rods,  which  are  covered  in  the  simple  induction  coil  by 
a  movable  brass  tube  (the  tube  of  Duchenne).  Outside  of  the 
core  and  the  primary  current  is  a  second  coil,  usually  consisting 
of  a  great  many  turns  of  fine  copper  wire.  The  ends  of  this  coil 
are  also  connected  Avith  the  binding  posts.  AVhen  the  current 
from  the  cell  passes  through  the  coil  of  coarse  wire — the  primary 
current — a  current  is  also  produced  in  the  secondary  coil  of  fine 
wire  because  the  passage  of  the  primary  current  makes  the  iron 
core  strongly  magnetic.  A  vibrator  is  placed  in  close  proximitj' 
to  the  iron  core.  When  the  current  passes  through  the  primary 
coil  and  becomes  magnetized,  the  steel  spring  of  the  vibrator  is 
attracted  and  breaks  the  current.  The  magnet  is  now  immediately 
released  and  the  spring  reasserts  itself.  The  control  of  the  cur- 
rent is  guided  by  moving  the  brass  tube;  the  gradual  removal  of 
the  tube  strengthens  the  current  and  vice  versa.  To  furnish  an 
approximate  guide  of  the  strength  of  the  current,  the  tube  of 
Duchenne  is  divided  into  ten  equal  parts  by  making  file  marks 
in  the  tube,  or  by  pasting  a  narrow  strip  of  paper,  on  which  the 
divisions  have  been  registered,  on  the  tvibe.  The  divisions  are  re- 
ferred to  as  degrees.  In  the  sledge  induction  coil  of  Du  Boys- 
Reymond  the  secondary  coil  is  moved  bodily  over  the  primary 
current.  The  registration  of  intensity  is  marked  on  a  scale  fas- 
tened to  the  apparatus,  which  is  divided,  according  to  the  size  of 
the  apparatus,  in  10,  50,  or  100  degrees.  This  instrument  is  much 
more  sensitive  than  the  tube  induction  coil,  and  an  exact  dif- 
ferentiation between  the  various  degrees  is  more  readily  obtained. 
The  small  faradic  battery  carries  three  binding  posts  and  fur- 
nishes three  definite  currents.  Posts  1  and  2  furnish  the  mild 
primary  current,  posts  2  and  3  furnish  the  more  intense  secondary 
current,  while  posts  1  and  3  furnish  the  strong  combined  current. 
The  latter  current  is  the  one  which  is  usually  made  use  of  for  our 
purposes.  The  positive  metallic  hand  electrode  is  held  in  the  hand 
by  the  patient,  while  the  negative  pole  carries  the  conducting 
cord,  to  which  a  specific  dental  electrode  is  attached.  This  dental 
electrode  may  consist  of  a  piece  of  hard  rubber  in  the  form  of 


DIAGNOSIS   OP   DISEASES   OF   PULP    BY    ELECTRIC    CURRENT         591 

a  penholder,  with  a  piece  of  German  silver  wire  passing  through 
its  body.  A  socket  is  left  at  each  end  for  the  attachment  of  the 
conducting  cord  and  the  copper  point.  The  latter  is  slightly 
roughened  to  carry  a  small  piece  of  Avet  cotton;  it  may  be  bent 
to  any  desired  angle.  A  serviceable  dental  electrode  may  be  made 
as  follows:  The  end  of  an  opaque  saliva  tube  is  heated  over  a 
Bunsen  flame,  drawn  to  a  point,  and  broken  off  so  as  to  leave  at 
its  curved  end  a  small  opening  about  one-sixteenth  of  an  inch  in 
width.  A  piece  of  No.  26  German  silver  wire,  about  eight  inches 
long,  is  soldered  to  a  small  disc  of  the  same  metal  so  as  to  fit  the 
neck  of  the  tube  snugly  at  about  one-quarter  of  an  inch  from 
its  smaller  opening.  The  wire  is  now  loosely  coiled,  and  its  other 
end  twisted  to  a  spiral,  which  should  fit  the  contact  pin  of  the 
conducting  cord.  The  coil  is  now  pushed  into  the  prepared  glass 
tube,  and,  if  necessary,  cemented  in  place  at  its  lower  end.  In 
using  the  electrode  a  piece  of  cotton  wet  with  salt  water  is  in- 
serted into  the  small  opening  and  the  other  end  is  attached  by 
means  of  the  conducting  cord  to  the  negative  pole  of  the  battery. 

The  Action  of  the  Faradic  Current  on  the  Pulp. — The  diag- 
nosis of  the  condition  of  the  pulp  for  clinical  purposes  resolves 
itself  into  hyperemia,  inflammation,  and  death  of  this  organ.  As 
far  as  simple  hyperemia  of  the  pulp  is  concerned,  the  routine 
therapeutic  treatment  is  so  well  knoAvn  that  no  further  discussion 
is  needed  at  this  moment.  If  inflammation  of  the  pulp  is  pres- 
ent— that  is,  when  micro-organisms  have  gained  access  to  the  pulp 
— the  experienced  practitioner  will  lose  no  time  in  destroying  this 
pulp.  The  treatment  of  pulp  gangrene  is  a  matter  of  specific  dis- 
cussion, which  has  no  interest  at  present. 

The  action  of  the  electric  current  on  a  sound  tooth  calls  forth 
a  definite  sensation  which  is  in  accordance  with  the  normal  re- 
action of  the  patient  to  electric  stimulation.  The  strength  of  the 
current  needed  for  this  purpose  varies  with  the  individual.  The 
sensation  manifests  itself  in  a  peculiar  tingling  sensation,  but  not 
in  pain.  This  point  is  known  as  the  irritation  point.  After  hav- 
ing established  the  irritation  point  in  a  sound  tooth  of  the  patient, 
and  after  having  expressed  it  in  figures  from  the  markings  on  the 
tube  of  Duchenne,  it  is  a  simple  matter  to  distinguish  a  diseased 
pulp  reaction  from  a  normal  pulp  reaction.  By  applying  these 
figures,  a  reliable  clue  for  the  diagnosis  of  existing  diseases  of 


592  APPENDIX 

the  pulp  is  furnished.    The  following  scheme  may  serve  as  a  guide 
for  making  a  diagnosis  by  means  of  the  faradic  current: 

1.  The  normal  pulp  responds  to  the  faradic  current  at  the  ir- 
ritation point. 

2.  The  irritated  pulp  responds  to  the  faradic  current  at  the 
irritation  point,  or  just  slightly  below  it. 

3.  The  inflamed  pulp  responds  to  the  faradic  current  below 
the  normal  irritation  point.  The  more  severe  the  inflammation,  the 
more  ready  the  response  to  the  current. 

4.  The  inflamed  pulp  with  pus  infiltration  (abscess  formation) 
responds  to  the  faradic  current  above  the  normal  irritation  point. 
The  more  severe  the  purulent  condition,  the  less  ready  the  response 
to  the  current. 

5.  The  dead  pulp  does  not  respond  at  all,  not  even  to  the  full 
strength  of  the  faradic  current. 

To  illustrate  this  diagnostic  scheme  by  figures  as  obtained  from 
measurements  with  the  tube  of  Duchenne,  the  following  data  may 
serve  as  examples: 

Degrees.  Diagnosis. 

1.  Upper  central  incisors 3.5  Normal    irritation    point. 

2.  First  upper  right  bicuspid 3  Pulp     irritation.         (The 

tooth  shows  a  slight 
carious  defect.) 

3.  First  lower  right  molar 1.5  Acute     pulpitis.         (The 

tooth  shows  a  deep 
carious    defect.) 

4.  Second  lower  left  molar 7.5  Purulent  pulpitis.      (The 

tooth  is  apparently  in- 
tact; it  has  a  large 
compound  amalgam  iill- 

5.  Second  upper  left  bicuspid No  response       Dead   pulp.      (The  tooth 

from  current.  has  a  large  cement  fill- 

ing-) 

The  Technique  of  Applying  the  Faradic  Current  to  the 
Tooth. — The  positive  metallic  hand  electrode  of  the  faradic  battery 
is  held  by  the  patient,  or  a  wet  cork  or  felt  electrode  is  fastened  to 
his  wrist.  The  negative  pole  carries  the  dental  electrode,  which 
is  manipulated  by  the  operator.  The  current  is  started  at  its  low- 
est amperage — that  is,  the  tube  of  Duchenne  is  completely  pushed 
over  the  core,  or  the  sledge  is  started  at  zero.    The  irritation  point 


DIAGNOSIS   OP    DISKASES   OF   PULP    BY    ELECTRIC    CURRENT         593 

of  the  patient  is  now  obtained  by  holding  the  dental  electrode 
against  any  of  the  apparently  sound  teeth.  The  upper  central 
incisors  are  preferably  selected  for  this  purpose.  The  wet  cot- 
ton of  the  electrode  is  placed  near  the  center  of  the  labial  surface 
of  the  incisor,  but  always  away  from  anj^  present  filling.  The 
tube  is  now  gradually  withdrawn  until  slight,  but  distinct,  sensa- 
tion is  noticed  by  the  patient.  The  sensation  must  never  be  ex- 
pressed as  pain.  The  number  on  the  scale  of  the  tube  is  read, 
and  the  same  maneuver  is  repeated  on  the  other  incisor.  The 
average  of  the  two  readings  furnishes  the  irritation  point  of  the 
patient  under  treatment.  It  has  been  suggested  by  An  der  Lahn^ 
to  place  both  electrodes  on  the  tooth,  one  lingually  and  one  la- 
bially,  and  then  pass  the  current  directly  through  the  crown  of 
the  tooth.  This  method  does  not  give  the  same  positive  results 
as  when  the  current  travels  through  the  long  axis  of  the  tooth 
and  thereby  passes  through  the  entire  pulp.  The  average  irrita- 
tion point  is  not  the  same  for  every  tooth  and  for  every  patient. 
A  layer  of  thick  enamel  on  a  heavy  body  of  dentin  requires  a 
stronger  current  and  vice  versa.  Consequently  the  irritation  point 
in  the  young  is  much  lower  than  in  old  individuals.  The  con- 
dition of  the  nervous  system  of  the  patient  may  also  influence 
the  response  to  the  current;  a  disturbed  psyche  is  usually  much 
more  sensitive  to  electric  stimulation  than  a  normal  condition. 
If  the  electrode  is  placed  on  or  very  close  to  a  metallic  filling  in 
a  vital  tooth,  the  response  is  very  pronounced,  and  even  painful, 
as  compared  to  the  same  amount  of  current  passing  through  a 
tooth  without  a  metallic  filling.  This  is  also  true  if  the  electrode 
is  placed  on  a  thin  shell  of  enamel  which  covers  a  metallic  fill- 
ing. The  severity  of  the  shock  depends  on  the  size  of  the  filling. 
All  filling  materials — gold,  amalgam,  or  the  cements,  with  the  ex- 
ception of  gutta-percha — are  better  electric  conductors  than  en- 
amel. The  tooth  under  observation  must  be  dry,  and  not  in  too 
close  contact  with  its  neighbors,  as  the  current  may  switch  to  those 
teeth.  The  close  proximity  of  large  contour  fillings  or  metallic 
crowns  deserves  special  care.  In  such  cases  the  rubber  dam  or 
strips  of  the  dam  placed  between  the  adjacent  teeth  is  necessary 
for  isolation.  The  electrode  must  not  be  placed  too  near  the  gum 
line,  or  the  gum  tissue  will  react  before  the  pulp  is  reached.    The 

•An  der  Lahn:  Loc.  cit. 


594  APPENDIX 

sensation  felt  on  the  gum  is  quite  different  from  that  in  the  pulp. 
It  is  not  acute,  but  manifests  itself  as  a  tickling  or  crawling  feel- 
ing. Devitalized  teeth  which  carry  fillings  will  also  react  if  the 
electrode  is  placed  on  or  near  the  filling;  they  will  not  react  if 
the  electrode  is  placed  on  sound  enamel,  provided  that  the  root 
filling  consists  of  gutta-percha.  If  the  root  carries  a  metallic  post, 
a  prompt  shock  is  felt  from  the  current.  If  a  present  filling 
reaches  the  gum  line,  a  very  quick  and  painful  response  is  ex- 
perienced, even  from  a  mild  current,  when  placed  in  contact  with 
the  filling.  The  absence  of  enamel  acts  somewhat  similar  to  the 
presence  of  a  filling.  A  shock  is  usually  produced  when  the  cur- 
rent is  placed  on  exposed  dentin,  which  must  therefore  be  avoided. 
A  tooth  with  a  dead  pulp,  but  with  a  sound  crown,  will  also  re- 
act to  the  current  if  an  acute  pericementitis  is  present.  Usually, 
however,  a  somewhat  stronger  current  is  required  than  that  which 
is  necessary  to  establish  the  irritation  point.  In  multirooted  teeth 
the  pulp  may  be  dead  in  one  canal  and  highly  inflamed  in  another 
canal.  In  such  cases  a  reaction  similar  to  that  obtained  from  pur- 
ulent pulpitis  is  usually  observed. 

The  examination  of  the  pulp  by  means  of  the  faradic  current 
requires  a  thorough  mastering  of  the  many  details  connected  there- 
with. The  practitioner  can  best  familiarize  himself  with  the  cur- 
rent by  using  his  own  battery  and  induction  coil,  and  by  testing 
the  instruments  on  himself  and  on  an  experimental  patient.  The 
teeth,  gums,  lips,  and  tongue  are  the  organs  which  should  be  pre- 
liminarily tested.  Before  testing  a  tooth  for  pulp  disturbances,  it 
is  always  advisable  to  establish,  if  possible,  the  irritation  point  in 
the  corresponding  sound  tooth  of  the  opposite  side  of  the  jaw. 
The  difference  of  the  recorded  figures  furnishes  the  base  for  its 
diagnostic  utilization.  It  is  understood,  of  course,  that  no  thera- 
peutic measures  have  been  previously  applied  to  the  teeth  under 
consideration  or  to  the  general  system ;  their  presence  would  ma- 
terially influence  the  reaction  of  the  current.  Some  interesting 
experiments  in  this  respect  have  been  made  by  Schroder.^  Mor- 
phin  administered  in  average  doses  will  reduce  the  reaction  of  the 
current  three  to  four  degrees  below  the  normal  irritation  point. 
Its  action  manifests  itself  about  fifteen  to  twenty  minutes  after 
its  administration,  and  lasts  from  one  and  a  half  to  two  hours. 

*  Schroder:  Loc.  cit. 


IMMEDIATE    TREATMENT   OP   ACUTE   POISONING  595 

while  chloral  hydrate  in  15-grain  (1  Gm.)  doses  acts  within  three 
to  four  minutes,  and  reduces  the  scale  two  to  three  degrees,  but 
its  action  lasts  only  from  ten  to  fifteen  minutes. 

The  action  of  bromids  and  of  bromural  is  also  very  pronounced. 
Their  administration  for  the  purpose  of  reducing  the  hypersensi- 
tiveness  of  teeth  which  have  to  undergo  operative  procedures  Is 
referred  to  under  Sedatives. 

The  faradic  current  as  a  diagnostic  aid  in  pulp  diseases  is  far 
superior  to  any  other  method  so  far  known,  but  it  should  be  re- 
membered that  it  is  not  absolute  in  every  case. 

IMMEDIATE  TREATMENT  OF  ACUTE  POISONING. 

General  Directions. 

When  a  poison  has  been  swallowed,  the  stomach  should  at  once 
be  evacuated  with  the  stomach  tube,  or,  in  its  absence,  with  a 
fountain  syringe.  If  corrosives  have  been  swallowed  and  the 
mucous  membranes  are  greatly  swollen,  the  stomach  tube  is  not 
indicated,  as  laceration  of  the  soft  tissues  may  follow.  Emetics 
are  of  prime  importance.  Certain  metallic  salts,  especially  copper 
sulphate  in  3-grain  (0.2  Gm.)  doses,  and  zinc  sulphate  in  10-grain 
(0.65  Gm.)  doses,  dissolved  in  a  glassful  of  water,  act  very 
promptly.  If  the  patient  is  unable  to  swallow,  apomorphin  hydro- 
chlorid,  1-10  grain  (0.006  Gm.),  hypodermically,  acts  promptly 
and  vigorously.  As  an  emergency  remedy  a  tablespoonful  of 
ground  mustard  stirred  in  a  cupful  of  tepid  water  usually  produces 
quick  vomiting.  If  the  poison  is  of  an  unknown  origin,  emetics, 
bland  liquids,  and  stimulants,  together  with  suitable  systematic 
treatment,  is  indicated. 

Acetic,  Hydrochloric,  Nitric,  Nitro-Hydrochloric,  and 
Sulphuric  Acids. 

No  emetic  should  be  given.  To  dilute  and  neutralize  the  acid, 
milk  mixed  with  chalk,  whiting,  magnesia,  or  baking  soda,  strong 
soap  suds,  or  white  of  egg  beaten  up  with  water,  is  given;  later 
oil  and  mucilaginous  drinks  of  flaxseed  or  slippery  elm  are  indi- 
cated. Usually  intense  ulceration  follows  the  acid  burns.  To  re- 
lieve pain,  morphin  sulphate,  14  grain  (0.015  Gm.),  or  tincture 
of  opium,  15  drops  (1  C.c),  is  administered. 


596  appendix 

Hydrocyanic   Acids  and  all   Cyanids,   Alcohol,    Chloroform, 
Ether,  Chloral  Hydrate,   Gasolin,   Carbon  Disulphid,  and 

SULPHURETS  OF  THE  AlKALIES. 

Hydrocyanic  acid  and  cyanids  require  very  prompt  measures ; 
they  are  quick  and  powerful  poisons.  Emetics  may  be  given  if 
necessary.  The  patient  is  put  in  a  recumbent  position,  the  head 
lowered,  and  plenty  of  fresh  air  allowed  for  free  respiration.  Per- 
sistent artificial  respiration  should  be  instituted  if  needed.  Keep 
the  body  warm,  and  try  to  arouse  the  patient  with  ammonia 
vapors;  put  cold  douches  to  his  head  and  apply  friction  to  the 
extremities.  Strong  stimulants — Avhisky,  nitroglycerin  solution  in 
i/2-di'op  doses,  etc. — are  indicated. 

Oxalic  Acid  and  its  Salts. 

Give  chalk  or  whiting  mixed  with  two  tablespoonfuls  of  vinegar 
and  an  equal  quantity  of  water;  do  not  give  soda  or  potash  with 
the  object  of  neutralizing  the  acid.     Vomiting  should  be  induced 
at  once  and  followed  by  olive  oil  or  mucilaginous  drinks.     Gen 
eral  stimulants — whisky,  etc. — and  warmth  applied  to  the  extremi 
ties  are  essential. 

Phenol  (Carbolic  Acid)  and  its  Compounds,  Cresol,  Creosote, 
Lysol,  and  Resorcinol. 

Induce  vomiting  and  give  large  quantities  of  sodium  sulphate 
solution  in  the  early  stages.  Remember  that  alcohol  is  not  a  chemic 
antidote  for  phenol  or  its  compounds.  Later  give  bland  liquids, 
olive  oil,  and  general  stimulants  as  required. 

Caustic  Alkalies  and  Ammonia. 

Promote  vomiting  by  large  draughts  of  warm  water.  Mild 
acids  in  the  form  of  diluted  vinegar  or  lemon  juice  are  indicated, 
which  should  be  followed  by  olive  oil,  white  of  egg  beaten  up 
with  water,  and  mucilaginous  drinks.  Severe  pain  calls  for  mor- 
phin  sulphate,  i^  grain  (0.015  Gm.),  or  tincture  of  opium,  15 
drops  (1  C.c). 

Arsenic  and  its  Compounds. 

Promote  vomiting  with  large  draughts  of  warm  water  and  ad- 
minister at  once  hydrated  oxid  of  iron   (the  official  antidote  for 


IMMEDIATE   TREATMENT   OF   ACUTE   POISONING  597 

arsenic)  or  dialysed  iron.  The  official  antidote  may  be  prepared 
extemporaneously  by  mixing  a  teaspoonful  of  calcined  magnesia 
with  a  cupful  of  water,  add  three  teaspoonfuls  of  tincture  of  iron 
chlorid,  mix  well,  and  give  the  whole  of  it  at  once.  This  is  to 
be  followed  with  olive  oil,  white  of  egg  beaten  up  with  water,  and 
mucilaginous  drinks. 

Antimony  Salts,  Copper  Salts,  Iodin  and  its  Preparations, 
Mercury  Salts,  Potassium  Bichromate,  Tartar  Emetic, 
Tin  and  its  Salts,  Zinc  and  its  Salts,  Colchicum,  Can- 
tharides,  and  the  Oils  of  Croton,  Savin,  and  Pansy. 

Induce  vomiting,  which  is  usually  produced  by  the  metallic  salts 
themselves.  Give  large  draughts  of  raw  white  egg  (about  half 
dozen  or  more)  beaten  up  with  water,  or  flour  stirred  in  water, 
strong  tea  or  coffee,  and  general  stimulants.  To  relieve  pain  and 
tenesmus,  morphin  sulphate,  I/4  grain   (0.015  Gm.),  is  indicated. 

Barium  and  Lead  Salts. 

Give  magnesium  sulphate,  4  drams  (15  Gm.),  or  sodium  sul- 
phate, 1  ounce  (30  Gm.),  dissolved  in  a  large  tumblerful  of  water. 
Promote  vomiting  with  warm  water  or  with  mustard,  and  follow 
with  milk  or  demulcent  drinks.  Pain  is  relieved  by  morphin 
sulphate,  14  graiii  (0.015  Gm.),  or  tincture  of  opium,  15.  drops 
(1  C.c). 

Silver  Nitrate. 

Give  common  salt  one-half  tablespoonful  dissolved  in  a  tumbler- 
ful of  warm  water,  and  induce  vomiting;  later,  large  draughts 
of  demulcent  drinks — starch,  flaxseed,  or  slippery  elm  stirred  in 
water — are  indicated. 

Phosphorus  (Rat  Paste,  Etc.) 

Give  a  prompt  emetic — copper  sulphate,  3  grains  (0.02  Gm.), 
dissolved  in  a  tumblerful  of  water — every  five  minutes.  Old,  thick 
oil  of  turpentine  in  1-dram  (4  C.c.)  doses,  suspended  in  flour  water 
and  repeated  every  hour,  is  much  lauded.  Do  not  give  oils  or 
fats.  Milk  of  magnesia  is  often  beneficial.  When  indicated,  give 
general  stimulants. 


598  appendix 

Atropin,  Cocain,  Gelsemin,  Pilocarpin,  and  all  Preparations 
Containing  These  Alkaloids. 

Induce  vomiting,  give  large  draughts  of  warm  Avater,  strong 
coffee  and  tea,  and  general  stimulants.  If  the  patient  is  drowsy, 
rouse  him  with  ammonia  vapors;  apply  heat  to  the  extremities 
and  institute  artificial  respiration  if  necessary. 

Aconite,  Cotton  Root,  Digitalis,  Ergot,  Lobelia,  Tobacco,  Vera- 
TRUM,  AND  Preparations  Containing  These  Substances. 

Give  an  emetic,  which  should  be  followed  with  large  draughts 
of  warm  water,  strong  tea  or  coffee.  Keep  the  patient  in  a  hori- 
zontal position,  apply  warmth  and  friction  to  the  extremities,  and 
use  artificial  respiration  if  needed. 

Opium  and  its  Preparations,  Morphin  and  its  Salts,  and 
Indian  Hemp. 

If  necessary,  vomiting  should  be  induced.  Give  strong  tea  or 
coffee  and  large  draughts  of  warm  water.  Keep  the  patient  awake, 
and,  if  possible,  in  motion.  A  cold  douche  is  beneficial.  Strych- 
nin sulphat,  1-30  grain  (0.002  Gm.),  and  atropin  sulphate,  1-100 
grain  (0.0006  Gm.),  administered  hj-podermically,  are  often  of 
benefit.  Persistent  artificial  respiration  should  be  kept  up,  even 
after  life  seems  to  be  extinct. 

Nux  Vomica  and  its  Preparations,  Strychnin  and  its  Salts, 
and  Fishberries  (Cocculus  Indicus). 

Induce  vomiting,  followed  by  large  draughts  of  warm  water,  and 
give  tannic  acid  in  1  per  cent  solution  of  iodid  of  starch.  Spasms 
are  relieved  by  inhalation  of  chloroform,  or  by  chloral  hydrate. 
15  grains  (1  Gm.)  dissolved  in  a  tumblerful  of  water.  Evacuate 
the  bowels  and  give  the  patient  absolute  rest. 

FORMALDEHYD  AND  ITS  SOLUTIONS. 

Give  ammonia  in  very  diluted  solutions  and  demulcent  drinks. 
General  stimulants  should  be  given  when  indicated. 

Wood  Alcohol. 

Give  immediately  a  tablespoonful  of  common  salt  dissolved  in  a 
large  tumblerful  of  warm  water,  and  repeat  at  short  intervals. 


GLOSSARY   OF    THERAPEUTIC    TERMS  599 

If  necessary,  stimulate  the  respiration  with  strychnin  sulphate, 
1-30  grain  (0.002  Gm.),  hypodermically,  and  give  strong  coffee 
or  tea. 

Decayed  Meat  or  Vegetables. 

These  materials  are  often  productive  of  ptomain  poisoning.  In- 
duce vomiting  and  cleanse  the  bowels  with  full  doses  of  castor  oil. 
Strong  stimulants,  and  heat  and  friction  applied  to  the  extremities, 
are  beneficial. 

Poisonous  Fungi. 

Evacuate  the  stomach  as  quickly  as  possible  by  promptly  acting 
emetics.  Give  atropin  sulphate,  1-100  grain  (0.0006  Gm.),  hypo- 
dermically, and  tannic  acid  in  the  form  of  strong  tea  or  coffee. 

GLOSSARY  OF  THERAPEUTIC  TERMS. 

The  following  are  brief  definitions  of  the  more  important  tech- 
nical terms  employed  to  designate  the    medicinal    properties    of 

remedies : 

Abortives — Drugs  which  produce  abortion — Oil  of  savin. 

Absorbents — Drugs  which  promote  absorption — Charcoal. 

Abstergents — Detergents. 

Adjuvants — Substances  which  assist  in  the  action  of  the  principal 
drugs. 

Alteratives — Drugs  which  so  favorably  modify  nutrition  as  to 
overcome  morbid  processes — Potassium  iodid. 

Anesthetics — Drugs  which  produce  general  insensibility  to  pain 
— Chloroform. 

Anesthetics,  local — Drugs  which  produce  insensibility  to  pain  in 
a  localized  area  of  tissue — Cocain. 

Analeptics — Restorative  drugs — Validol. 

Analgesics — Drugs  which  allay  pain — Acetanilid. 

Anaphrodisiacs — Drugs  which  depress  sexual  desire — Camphor- 
ated opium. 

Anodynes — Drugs  which  relieve  pain — Morphin. 

Antacids — Drugs  which  neutralize  acids — Sodium  bicarbonate. 

Anthelmintics — Drugs  which  destroy  intestinal  worms — Santonin. 

Antiarthritics — Drugs   which   relieve  gout — Hexamethylenamin. 

Antiemetics — Drugs  which  relieve  vomiting — Cerium  oxalate. 


600  APPENDIX 

Anticonvulsants — Drugs      which      relieve      spasms— Potassium 

bromid. 
Antihydropics — Drugs  which  relieve  dropsical  conditions — Potas- 
sium acetate. 
•  ANTiLrrHics — Drugs  which  prevent  the  formation  of  stone  or  cal- 
culus— Lithium  carbonate. 
Antiluetics — Antisyphilitics. 
Antiperiodics — Drugs  which  relieve  malarial  or  recurrent  fevers — 

Quinin. 
Antiphlogistics — Drugs  which  counteract  inflammation  and  fever 

— Aconite. 
Antipyretics — Drugs  which  reduce  temperature  or  relieve  fever 

— Antipyrin. 
Antirheumatics — Drugs  which  relieve  or  prevent  rheumatism — 

Sodium  salicylate. 
Antiseptics — Drugs  which  inhibit  the  growth  of  micro-organisms 

— Diluted  phenol. 
Antisialogogues — Drugs    which    decrease    the    flow    of    saliva— 

Atropin. 
Antispasmodics — Drugs    which    relieve    nervous    irritability    and 

spasms — Sodium  bromid. 
Antisyphilitics — Drugs  used  in  the  treatment  of  syphilis — JMer- 

cury. 
Antitoxins — Defensive  proteins  developed  in  the  body  as  a  result 

of  the  inoculation  of  a  poison  and  acting  as  a  neutralizer  of  the 

poison — Diphtheria  antitoxin. 
Antizymotics — Drugs  which  inhibit  fermentation — Salicylic  acid. 
Aperients — Mild  cathartics. 

Aphrodisiacs — Drugs  which  stimulate  sexual  impulse — Nux  vomica. 
Aromatics — Drugs  characterized  by  a  spicj^  odor  and  taste ;  used 

to  stimulate  the  mucous  membrane    of    the    intestinal    tract — 

Colombo. 
Astringents — Drugs  which  induce  contractibility  of  tissues  and 

arrest  discharges — Tannic  Acid. 
'  Blisters — Drugs  which,  applied  locally,  cause  inflammatory  exuda- 
tion of  serum;  produce  vesication^ — Cantharides. 
Calefacients — Drugs  which,  applied  externally,  produce  a  sense 

of  warmth — Capsicum. 
Cardiac  Depressants — Drugs  which  decrease  the  heart's  action — 

Amyl  nitrite. 


GLOSSARY    OF    THERAPEUTIC    TERMS  601 

Cardiac  Stimulants — Drugs  which  increase  the  heart's  action — 
Digitalis. 

Carminatives — Drugs  which  expel  air  from  the  bowels;  relieve 
flatulence — Oil  of  caraway  seed. 

Cathartics — Mild  purgatives  which  quicken  and  increase  expul- 
sion from  the  bowels — Sodium  sulphate. 

Caustics — Drugs  which  destroy  living  tissue — Trichloracetic  acid. 

Cholagogues — Drugs  which  promote  the  flow  of  bile — Calomel. 

CoNVULSANTS — Drugs  which  cause  convulsions — Cannabis  indica. 

Correctives — Drugs  which  correct  or  render  more  palatable  the  ac- 
tion of  other  drugs. 

Corrigents — Correctives. 

Counterirritants — Substances  which,  by  counterirritation,  relieve 
some  other  irritation — Tincture  of  iodin. 

Demulcents — Mucilaginous  substances  which,  in  solution,  soothe 
or  protect  inflamed  or  abraded  surfaces — Mucilage  of  acacia. 

Dentifrices — Preparations  which  cleanse  the  teeth. 

Deodorants — Drugs  which  destroy  foul  odors — Potassium  perman- 
ganate. 

Depilatories — Substances  which  remove  hair — Barium  sulphid. 

Depletives — Drugs  which  remove  fluids  from  the  system — Magne- 
sium sulphate. 

Depressants — Sedatives. 

Detergents — Substances  which  cleanse  or  purify — Soap. 

Diaphoretics — Drugs  which  produce  slight  sweating-^Dover 's 
powder. 

Dietetics — Substances  which  regulate  the  diet. 

DiGESTANTS — Fcrmcuts  which  aid  digestion — Pepsin. 

Diluents — Substances  which  dilute  secretions  and  excretions ;  also 
render  drugs  less  irritant — Water. 

Disinfectants — Drugs  w^hich  chemically  destroy  and  render  infec- 
tious material  sterile  or  inert — Chlorinated  lime. 

Diuretics — Drugs  which  increase  or  promote  secretion  of  urine — 

Diuretin. 
Drastics — Drugs  which  produce  violent  purgation — Croton  oil. 
EcBOLics — Drugs  which  accelerate  labor — Ergot. 
Emetics — Drugs  which  cause  vomiting — Apomorphin. 
Emmenagogues — Drugs  which  stimulate  menstruation — Tansy. 
Emollients — Substances  which  mechanically  soften   and    protect 

tissues — Petrolatum. 


602  APPENDIX 

Epispastics — Blisters. 

Errhines — Drugs  which  increase  nasal  secretions — Boric  acid. 

EscHAROTics — Substances  which  produce  caustic  effects — Silver 
nitrate. 

Etiotropics — Drugs  which  act  on  the  causes  of  disease. 

EvACUANTS — Drugs  which  evacuate;  chiefly  applied  to  purgatives, 
and  also  to  emetics  or  diuretics. 

Expectorants — Drugs  which  act  on  the  pulmonic  mucous  mem- 
brane and  increase  or  alter  its  secretion — Ipecac. 

Febrifuges — Drugs  which  dispel  or  reduce  fevers — Acetanilid. 

Galactagogues — Drugs  which  increase  the  secretion  of  milk — Fen- 
nel. 

Hemostatics — Drugs  which  arrest  hemorrhage — Stypticin. 

Hepatics — Drugs  which  act  on  the  liver — Sodium  phosphate. 

Hydragogues — Purgatives  which  cause  large,  watery  discharges — 
Jalapin. 

Hypnotics — Drugs  which  produce  sleep — Sulfonal. 

Irritants — Drugs  which  cause  irritation — Ammonia  water. 

Laxatives — Mild  purgatives. 

Motor  Excitants — Drugs  which  excite  motor  activity — Strychnin. 

Motor  Depressants — Drugs  Avhich  lessen  motor  activity — Curare. 

Mydriatics — Drugs  which  cause  dilation  of  the  pupil ;  mydriasis — 
Atropin. 

Myotics — Drugs  which  cause  contraction  of  the  pupil;  myosis — 
Physostigmin. 

Narcotics — Drugs  which  produce  sleep  or  stupor  and  simultane- 
ously relieve  pain — Opium, 

Neurotics — Drugs  which  act  on  the  nervous  system — Strychnin. 

Nutrients — Substances  which  nourish — Foodstuffs. 

Obtundents — Drugs  which  locally  alleviate  pain  by  partial  anes- 
thesia— Oil  of  cloves. 

Organotropics — Drugs  which  influence  the  function  of  organs. 

Oxytocics — Drugs  which  stimulate  uterine  contraction — Ergot. 

Peristaltics — Drugs  which  increase  peristalsis — Magnesium  ci- 
trate. 

Prophylactics — Substances  which  prevent  contracting  or  develop- 
ing disease. 

Protectives — Drugs  which  protect  a  part — Collodion. 

Ptyalogogues — Sialogogues. 


DIAGNOSTIC   ACIDS  603 

Purgatives — Drugs  which  cause  copious  discharge  from  the  bowels 
— Aloin. 

Refrigerants. — Drugs  which  decrease  the  bodily  temperature — 
Ethyl  chlorid. 

Revulsants — Drugs  which,  by  causing  irritation,  draw  nervous 
force  and  blood  from  a  distant  diseased  part ;  counterirritation. 

Rubefacients — Drugs  which  cause  irritation  and  redness — Cap- 
sicum. 

Sedatives — Drugs  which  decrease  functional  activity — Henbane. 

Sialogogues — Drugs  which  stimulate  the  salivary  glands  to  secre- 
tion— Pilocarpin. 

Somnifacients — Soporifics. 

Soporifics — Drugs  which  cause  profound  sleep — Chloral  hydrate. 

Sorbefacients — Drugs  which  cause  absorption. 

Specifics — Drugs  which  have  a  direct  curative  influence  on  certain 
specific  diseases — Mercury  on  syphilis. 

Stimulants — Drugs  which  increase  functional  activity — Alcohol. 

Stomachics — Stimulants  to  the  stomach — Nux  vomica. 

Styptics — Local  hemostatics. 

SuDORiFics — Diaphoretics. 

Teniafuges — Drugs  which  expel  tape  worms — Pelleterin. 

Tonics — Drugs  which  restore  the  normal  tone  by  stimulating  nutri- 
tion. 

Topics — Local  applications. 

Vermicides — Drugs  which  kill  intestinal  worms — Thymol. 

Vermifuges — Drugs  which  cause  expulsion  of  intestinal  worms — 
American  worm  seed.. 

Vesicants — Blisters. 

VuLNERARiES — Drugs  which  promote  healing  of  wounds — Iodo- 
form. 

DIAGNOSTIC  AIDS. 

Frequency  of  Pulse. 

At  birth    130  to  150  times  a  minute. 

At  the  first  year 100  to  130 

At  the  seventh  year   72  to     90 

At  the  time  of  puberty    80  to     85 

At  middle  life  69  to     75 

At  old  age  50  to     60 


604 


APPENDIX 


Frequency  of  Respiration. 

At  the  first  year 35  times  a  minute. 

At  the  second  year    25     "  " 

At  the  time  of  puberty   20     "  " 

Above  twenty  years  of  age 18     "  " 


Temperature  of  the  Body. 


Normal  temperature 97i/2°  to     981^°  F.  (36.3°  to  36.9*  C.) 

Feverishness  99° 

Slight   fever    100° 

Moderate  fever   102° 

High    fever    104° 

Intense  fever 105°  F.  (40.6°  C.) 


to  100° 

F. 

(37.3°  to  37.8° 

C.) 

to  101° 

F. 

(37.8°  to  38.4° 

C.) 

to  103° 

F. 

(38.9°  to  39.5° 

C.) 

to  105° 

F. 

(40.°     to  40.6* 

C.) 

Comparison  Between  Temperature  and  Pulse. 


A  temperature  of  98°  F.  (36.7°  C.) corresponds  to  a  pulse  of  60 


99° 
100° 
101° 
102° 
103° 
104° 
105° 
106° 


F. 
F. 
F. 
F. 
F. 
F. 
F. 
F. 


(37.2° 

(37.8° 

(38.4° 

(38.9° 

(39.5° 

(40.° 

(40.6= 

(41.2° 


C). 
C). 
C), 
C), 
C), 
C), 
C), 
C). 


70 
80 
90 
100 
110 
120 
130 
140 


THERMOMETRIC    EQUIVALENTS 


605 


THERMOMETRIC  EQUIVALENTS. 

To  reduce  Centigrade  degrees  to  those  of  Fahrenheit,  nmltiply 
by  9,  divide  by  5,  and  add  32;  or,  degrees  Centigrade  X 1-8+32= 
degrees  Fahrenheit. 

To  reduce  Fahrenheit  degrees  to  those  of  Centigrade,  subtract 
32,  multiply  by  5,  and  divide  by  9 ;  or,  degrees  — 32-r-1.8=degrees 
Centigrade. 


Degrees 

Degrees 

Degrees 

Degrees 

Cent. 

Fahr. 

Cent. 

Fahr. 

Cent. 

Fahr. 

Cent. 

Fahr. 

-20 

-4. 

17 

62.6 

54 

129.2 

91 

195.8 

-19 

-2.2 

18 

64.4 

55 

131. 

92 

197.6 

-18 

-0.4 

19 

66.2 

56 

132.8 

93 

199.4 

-17 

1.4 

20 

68. 

57 

134.6 

94 

201.2 

-16 

3.2 

21 

69.8 

58 

136.4 

95 

203. 

-15 

5. 

22 

71.6 

59 

138.2 

96 

204.8 

-14 

6.8 

23 

73.4 

60 

140. 

97 

206.6 

-13 

8.6 

24 

75.2 

61 

141.8 

98 

208.4 

-12 

10.4 

25 

77. 

62 

143.6 

99 

210.2 

-11 

12.2 

26 

78.8 

63 

145.4 

100 

212. 

-10 

14. 

27 

80.6 

64 

147.2 

101 

213.8 

-  9 

15.8 

28 

82.4 

65 

149. 

102 

215.6 

-   8 

17.6 

29 

84.2 

66 

150.8 

103 

217.4 

-   7 

19.4 

30 

86. 

67 

152.6 

104 

219.2 

-  6 

21.2 

31 

87.8 

68 

154.4 

105 

221. 

-   5 

23. 

32 

89.6 

69 

156.2 

106 

222.8 

-  4 

24.8 

33 

91.4 

70 

158. 

107 

224.6 

-  3 

26.6 

34 

93.2 

71 

159.8 

108 

226.4 

-   2 

28.4 

35 

95. 

72 

161.6 

109 

228.2 

-   1 

30.2 

36 

96.8 

73 

163.4 

110 

230. 

0 

32. 

37 

98.6 

74 

165.2 

111 

231.8 

1 

33.8 

38 

100.4 

75 

167. 

112 

233.6 

2 

35.6 

39 

102.2 

76 

168.8 

113 

235.4 

3 

37.4 

40 

104. 

77 

170.6 

114 

237.2 

4 

39.2 

41 

105.8 

78 

172.4 

115 

239. 

5 

41. 

42 

107.6 

79 

174.2 

116 

240.8 

6 

42.8 

43 

109.4 

80 

176. 

117 

242.6 

7 

44.6 

44 

111.2 

81 

177.8 

118 

244.4 

8 

46.4 

45 

113. 

82 

179.6 

119 

246.2 

9 

48.2 

46 

114.8 

83 

181.4 

120 

248. 

10 

50. 

47 

116.6 

84 

183.2 

121 

249.8 

11 

51.8 

48 

118.4 

85 

185. 

122 

251.6 

12 

53.6 

49 

120.2 

86 

186.8 

123 

253.4 

13 

55.4 

50 

122. 

87 

188.6 

124 

255.2 

14 

57.2 

51 

123.8 

88 

190.4 

125 

257. 

15 

59. 

52 

125.6 

89 

192.2 

126 

258.8 

16 

60.8 

53 

127.4 

90 

194. 

127 

260.6 

606 


APPENDIX 

DOSE  TABLE. 


The  doses  given  in  this  table  are  those  commonly  employed  for 
adults  and  per  mouth  unless  otherwise  stated.  The  figures  in  the 
first  column  of  doses  represent  grains  when  the  remedy  is  a  solid 
and  minims  when  it  is  a  liquid.  The  figures  in  the  second  col- 
umn signify  grams  when  the  remedy  is  a  solid  and  cubic  centi- 
meters when  it  is  a  liquid. 


Remedy 


Abstract,  aconite 

aspidosperma 

belladonna 

cannabis  indica 

conium 

digitalis 

gelsemium 

hyoscyamus 

ignatia 

ipecac 

jalap 

nux  vomica 

Phytolacca 

pilocarpus . . 

podophyllum 

senega 

valerian 

veratrum  viride 

Acetanilid 

Acetal 

Acetone 

Acid,  acetic 

agaricic 

anisic 

arsenous 

benzoic 

boric 

cacodylic 

camphoric 

carbolic 

cathartic 

citric 

cubebic 

di-iodo-salicylic 

filicic,  amorphous. . . 

gallic 

gynocardic 

hydriodic 

hydrobrom,  diluted . 

hydrochlor. ........ 

diluted 

hydrocinnamic 

hydrocyanic,  diluted 


Grains  or  minims 

Grams  or  C.c. 

V4— V2 

0.015 

—  0.03 

5—20 

0.3 

—  1.3 

V2— IV2 

0.03 

—  0.1 

1—3 

0.06 

—  0.2 

1—2 

0.06 

—  0.13 

1—3 

0.06 

—  0.2 

1—3 

0.06 

—  0.2 

2—5 

0.13 

—  0.3 

1—3 

0.06 

—  0.2 

3—20 

0.03 

—  1.3 

5—10 

0.03 

—  0.6 

V4— V2 

0.015 

—  0.03 

5—15 

0.3 

—  1. 

5—20 

0.3 

—  1.3 

2—5 

0.13 

—  0.3 

5—10 

0.3 

—  0.6 

5—15 

0.3 

—  1. 

1—1 

0.06 

—  0.13 

3—10 

0.2 

—  0.6 

120—180 

8. 

—12. 

5—15 

0.3 

—  1. 

15—40 

1. 

—  2.5 

Ve— V2 

0.01 

—  0.03 

5—15 

0.3 

—  1. 

Veo- V20 

0.001 

—  0.0003 

10—30 

0.6 

—  2. 

5—15 

0.3 

—  1. 

1—3 

0.06 

—  0.2 

10—30 

0.06 

—  2. 

V2— 2 

0.03 

—  0.13 

2—6  ' 

0.13 

—  0.4 

10—30 

0.6 

—  2. 

5—10 

0.3 

—  0.6 

8—20 

0.5 

—  1.3 

8—15 

0.5 

—  1. 

5—20 

0.3 

—  1.3 

V2— 3 

0.03 

—  0.2 

5—10 

0.3 

—  0.6 

30—90 

2. 

—  6. 

3—10 

0.2 

—  0.6 

10—30 

0.6 

—  2. 

10—20 

0.6 

—  1.3 

2—5 

0.13 

—  0.3 

DOSE  TABLE 


607 


Remedy 


Grains  or  minims 


Acid,  hypophosphorous 

lactic 

iaricic  (agaricic) 

mono-iodosalicylic 

naphtionic 

nitric,  diluted 

nitro-hydrochlorid,  diluted 

osmic 

oxalic 

oxynaphtoic 

paracreosotic 

phenylacetic 

phosphoric 

diluted 

picric 

propylacetic 

quinic 

salicylic 

santoninic 

sclerotic 

succinic 

sulphanilic 

sulphuric,  aromatic 

diluted 

sulphurous 

tannic 

tartaric 

valerianic 

Aconapellin 

Aconitin,  cryst 

Adonidin 

Agaricin 

Agathin , 

Agoniadin 

Airol 

Alantol 

Alcohol,  methylic 

Aletrin 

AUyl,  sulphid 

tribromid 

Alnuin 

Aloes 

purified -f 

Aloin 

Alphol 

Alphozon 

Alum 

emetic 

ammoniof  erric 

Aluminium  acetate 

chlorid 

Ammonia  water 

cone 

Ammoniac 

Ammonium,  acetate 


3—10 
15—30 

15—45 

10—20 

5—30 

5—20 

V64 
V2— 1 

1—3 

2—20 

2—4 

2—6 
20—60 
V2— 2 

3—5 

8—20 
10—40 

1—5 
V2-I 

5—15 
10—20 
10—20 
15—30 
15—60 

2—20 
10—30 

2—10 
V24— V12 

V640 V20O 

V16— V4 
V4-I 

2—8 
2—4 
2—5 

Ve- V2 

10—40 
1—3 
daily 
1—2 
5—10 
2—5 
2—20 
1—10 

V2— 2 
8—15 

V2— 2 
5—15 

60—120 
5—15 
5—10 
1—5 

10—30 
4—10 
5—15 

15—30 


Grama  or  C.c. 


0.2 

1. 

0.01 

1. 

0.6 

0.3 

0.3 

0.001 

0.03 

0.06 

0.13 

0.13 

0.13 

1.3 

0.03 

0.2 

0.5 

0.6 

0.06 

0.03 

0.3 

0.6 

0.6 

1. 

1. 

0.13 

0.6 

0.13 

0.0025 

0.0001 

0.004 

0.015 

0.13 

0.13 

0.13 

0.01 

0.6 

0.06 


—  0.6 

—  2. 

—  0, 

—  3. 
1 
2. 
1 


03 


—  1.3 


0.06 

0.3 

0.13 

0.13 

0.06 

0.03 

0.5 

0.03 

0.3 

4. 

0.3 

0.3 

0.06 

0.6 

0.25 

0.3 

1 


daily 


06 

2 

3 

25 

4 

13 

3 

3 

5 

3 

06 

3 
3 


6 

005 

0003 

016 

06 

5 

25 

3 

03 

5 

2 

13 

6 

3 

3 

6 

13 


—  0.12 


608 


APPENDIX 


Remedy 


Ammonium,  arsenate 

benzoate 

bicarbonate 

bisulphate 

bisulphite 

borate 

bromid 

camphorate 

carbolate  

carbonate 

chlorid 

embelate 

chlorid,  f errated 

fluorid 

formate 

glycerino-phosphate . . 

hypophosphite 

hyposulphite 

iodid 

phosphate 

picrate  

salicylate 

succinate 

sulphite 

sulphocarbol 

tartrate 

valerianate 

and  iron  tart 

Ammonamid 

Ammonol 

salicylate 

Ampelopsin 

Amygdophenin 

Amyl  nitrite 

salicylate,  daily 

valerianate 

Amylamine,  hydrochlorate 
Amylen-chloral 

hydrate 

Anesthesin 

Analgen 

Anemonin 

Anilin  sulphate 

Anilipyrin 

Anthemin 

Antiarthrin 

Antifebrin,  acetanilid 

Antikol 

Antimony  arsenate 

iodid 

oxid 

and  potassium  tart . . . 

Antinervin 

Antipyrin 

salicylate 

tannate 


Grains  or  minims 


V20— Vio 

10—30 
5—15 

10—30 

10—30 

10—20 

15—30 
1—3 
2—6 
5—20 
5—20 
3—6 
4—12 

V12— V4 
5—10 
3—6 

10—30 
5—30 
3—5 
5—20 

V4— IV2 
2—10 
1—3 
5—20 
1—5 
5—30 
2—8 

10—30 
5—15 
5—20 
8—20 
2—4 
5—15 
2—5 

30 
3—6 
3—15 
8—30 

15—30 
5 
5—15 

'/«— 1 

'U—Vh 

15—30 
1—3 
6—10 
3—10 
3—10 

Veo— V30 

V4-I 
1—3 

V32— Vs 

10—20 

10—20 
5—15 

20—45 


Grams  or  C.c. 


0.003 

0.6 

0.3 

0.6 

0.6 

0.6 

1. 

0.06 

0.13 

0.3 

0.3 

0.2 

0.25 

0.005 

0.3 

0.2 

0.6 

0.3 

0.2 

0.3 

0.015 

0.13 

0.06 

0.3 

0.06 

0.3 

0.13 

0.6 

0.3 

0.8 

0.5 

0.13 

0.3 

0.13 

2. 

0.2 

0.3 

0.5 

1. 

0.3 

0.3 

0.015 

0.05 

1. 

0.06 

0.4 

0.2 

0.2 

0.001 

0.015 

0.06 

0.002 

0.6 

0.6 

0.3 

1.3 


0.006 

2. 

1. 

2. 

2. 

1.3 

2. 

0.2 

0.4 

1.3 

1.3 

0.4 

0.8 

0.05 

0.6 

0.4 

2. 

2. 

0.3 

1.3 

0.1 

0.6 

0.2 

1.3 

0.3 

2. 

0.5 

2. 

1. 

1.3 

1.3 

0.25 

1. 

0.3 

0.4 
1. 
2. 
2. 

1. 

0.06 
0.1 
2. 
0.2 
0.6 
0.6 
0.6 

0.0002 
0.06 
0.2 
0.008 
1.3 
1.3 
1. 
.3 


DOSE   TABLE 


609 


Remedy 


Antirheumaticum 

Antisepsin 

Antispasmin 

Antithermin 

Apiol,  cryst 

fluid 

Apiolin 

Apocodein  hydrochlorate. . 

Apolysin . 

Apomorphin,  hydrochlorid 

Arbutin 

Arsenhemol 

Arsenic  bromid 

chlorid 

iodid 

Asafetida 

Asaprol 

Asclepin 

Asepsin 

Aspidium 

Aspidospermin 

Aspirin 

Atropin 

A  venin 

Balsam,  fir 

gurjun 

peru 

tolu 

traumatic 

Baptisin 

Barium  chlorid 

iodid 

sulphid 

Barosmin 

Basham's  mixture 

Bebeerin 

Benzacetin 

Benzanlid 

Benzene  (Benzol) 

Benzonaphthol 

Benzoparacresol 

Benzosol 

Benzoyleugenol 

Berberin 

hydrochlorid 

sulphate 

Betin 

Betol 

Bismal 

Bismuth,  albuminate 

benzoate 

betanaphtol 

carbolate 

citrate 

lactate 


Grains  or  minims 


1—2 

2—8 

Ve— 2  .  . 
1—3 
5—15 
5—10 
3 

V3— 1 

8—24 
V20— Vs 
5—15 
1—3 

Veo— Vu 

Veo— Vi5 

Veo— Vi5 

5—15 

5—15 

2—4 

2—8 

30—90 

1—2 

5—30 

V20— Veo 

V20— Veo 

5—30 
10—60 
10—30 

5—15 
30—60 
V2— 5 
Vio— V2 
Vio— V2 

V2-I 

2—4 

240—480 

V2— IV2 
8—15 
IV2— 15 
2—10 
5—15 
4—8 
3—15 
8—15 

V2— IV2 
5—10 
8—15 
2—4 
4—8 
2—5 
5—15 
5—15 
5—15 
5—15 
1—3 
5—15 


Grams  or  C.c. 


0.06 

0.13 

0.01 

0.06 

0.3 

0.3 

0.2 

0.02 

0.5 

0.003 

0.3 

0.06 

0.001 

0.001 

0.001 

0.3 

0.3 

0.13 

0.13 

2. 

0.06 

0.3 

0.0005 

0.0005 

0.3 
0.6 
0.6 
0.3 
2. 

0.03 
0.006 
0.006 
0.03 
0.13 
15. 
0.03 
0.5 
0.1 
0.13 
0.3 
0.25 
0.2 
0.5 
0.3 
0.3 
0.5 
0.13 
0.25 
0.13 
0.3 
0.3 
0.3 
0.3 
0.06 
0.3 


-  0.13 

-  0.5 

-  0.13 

-  0.2 

-  1. 

-  0.6 

-  0.06 

-  1.5 

-  0.008 

-  1. 

-  0.2 

-  0.004 

-  0.004 

-  0.004 

-  1. 

-  1. 

-  0.25 

-  0.5 

-  6. 

-  0.13 

-  2. 

-  0.001 

-  0.001 

-  2. 

-  4. 

-  2. 

-  1. 

-  4. 

-  0.3 

-  0.03 

-  0.03 

-  0.06 

-  0.25 
-30. 

-  1. 

-  1. 

-  1. 

-  0.6 

-  1. 

-  0.5 

-  1. 

-  1. 

-  0.1 

-  0.6 

-  1. 

-  0.25 

-  0.5 

-  0.3 

-  1. 

-  1. 

-  1. 

-  1. 

-  0.2 

-  1. 


610 


APPENDIX 


Remedy 


Bismuth,  nitrate  (tri-) 

oxid 

oxybromid 

oxyiodid  (subiod.) 

peptonized 

phosphate,  soluble 

pyrogallate 

resorcinate 

salicylate,  acid 

salicylate  (basic) 

subcarbonate 

subgallate 

subiodid  =  bismuth  oxy-iodid 

subnitrate 

tannate 

valerianate 

and  ammonium  citrate .... 

and  cinchonid.  iodid 

Bismuthan 

Blennostasin 

Borax 

Boroglycerin 

Borol 

Brayerin 

Brenzcain 

Bromalbacid. 

Bromal  hydrate 

Bromalin 

Bromamid 

Bromin 

Bromipin  (10  per  cent) 

Bromochinal 

BromocoU 

Bromoform , 

Bromo-hemol 

Brucin 

Bryonin 

Butyl-chloral  hydrate 

Cadmium  sulphate 

Caffein  triiodid 

Caffein 

citrated 

hydrobromate 

and  sodium  benzoate 

and  sodium  salicylate 

Calcium,  benzoate 

borate 

bromid 

bromo-iodid 

carbolate 

carbonate 

chlorid 

eosolate 

dioxid 


Grains  or  minims 

Grams  or  C.c. 

5—10 

0.3 

—  0.6 

5—15 

0.3 

—  1. 

5     6 

0.3 

—  0.4 

3—10 

0.2 

—  0.6 

30—60 

2. 

—  4. 

3—10 

0.2 

—  0.6 

5—15 

0.3 

—  1. 

3—8 

0.2 

—  0.5 

5—10 

0.3 

—  0.6 

5—15 

0.3 

—  1. 

5—30 

0.3 

—  2. 

4—8 

0.25 

—  0.5 

3—10 

0.2 

—  0.6 

5—40 

0.3 

—  2.5 

10—30 

0.6 

—  2. 

1—3 

0.06 

—  0.2 

2—5 

0.13 

—  0.3 

Ve— V4 

0.01 

—  0.05 

8—15 

0.5 

—  1. 

5—20 

0.3 

—  1.3 

20—40 

1.3 

—  2.5 

30—90 

2. 

—  6. 

5—10 

0.3 

—  0.6 

15—30 

1. 

—  2. 

1—5 

0.06 

—  0.3 

15—30 

1. 

—  2. 

3—15 

0.2 

—  1. 

20—60 

1.3 

—  4. 

5—15 

0.3 

—  1. 

1—3 

0.06 

—  0.2 

60—240 

4. 

—15. 

10—12 

0.6 

—  0.75 

15—75 

1. 

—  5- 

2—20 

drops 

15—30 

1. 

—  2. 

Vl2— V2 

0.005 

—  0.03 

'A— 2 

0.015 

—  0.13 

5—20 

0.3 

—  1.3 

Vi2— V. 

0.005 

—  0.01 

IV2— 4 

0.1 

—  0.25 

1—5 

0.06 

—  0.3 

2—10 

0.13 

—  0.6 

2—6 

0.13 

—  0.4 

3—10 

0.2 

—  0.6 

3—10 

0.2 

—  0.6 

10—30 

0.6 

—  2. 

1—5 

0.6 

—  0.3 

10—30 

0.6 

—  2. 

5—10 

0.3 

—  0.6 

2—5 

0.13 

—  0.3 

10—40 

0.6 

—  2.5 

5—20 

0.3 

—  1.3 

5—15 

0.3 

—  1. 

3—10 

0.2 

—  0.6 

DOSE   TABLE 

bll 

Remedy 

Grains  or  minims 

Grams  or  C.c. 

Calcium,  ferrophospholactate 

3—8 

3—10 

5—15 

10—30 
3—10 
2—5 
3—4 
3—10 
3—10 

10—20 
1—2 

Ve— V2 

10—30 
8—20 

V2— IV2 

IV2— 3 
1—5 
5—15 
1—3 
Vs-l 
5—15 
2—5 
5—10 
3—10 
2—5 
1—5 
1—5 
8—15 
V3— 1 
V2— IV2 
V1600 
■  Vio— V4 
1—5 
3—8 
5—8 

V240— Veo 

1—3 
1—5 
5—10 
IV2— 3 

10—30 
IV2— 3 
IV2— 3 
3 

10—30 
1—2 

10—40 
2—4 
5—10 
1—3 

10—30 

15—45 

15—30 
8—15 
3—6 

subcut. 

0.2 

0.2 

0.3 

0.6 

0.2 

0.13 

0.2 

0.2 

0.2 

0.6 

0.06 

0.01 

0.6 

0.5 

0.03 

0.1 

0.06 

0.3 

0.06 

0.02 

0.3 

0.13 

0.3 

0.2 

0.13 

0.06 

0.06 

0.5 

0.02 

0.03 

0.000 

0.006 

0.06 

0.2 

0.3 

0.000 

0.6 

0.06 

0.3 

0.1 

0.6 

0.1 

0.1 

0.2 

0.6 

0.06 

0.6 

0.13 

0.3 

0.06 

0.6 

1. 

1. 

0.5 

0.2 

—  0.5 

glycerinophos 

—  0.6 

hippurate 

—  1. 

hypophos 

—  2. 

hyposulphite 

—  0.6 

iodid 

—  0.3 

iodate 

—  0.25 

lactate 

—  0.6 

lactophosphate 

—  0.6 

phosphate 

—  1.3 

permanganate 

—  0.13 

quinovate 

—  0.03 

saccharate 

—  2. 

salicylate 

—  1.3 

santoninate 

—  0.1 

sulphid,  yellow 

—  0.2 

sulphite 

—  0.3 

sulphocarbol 

—  1. 

Calendulin 

—  0.2 

Calomel.          

—  0.06 

cathartic 

—  1. 

Camphor                 

—  0.3 

carbolated           

—  0.6 

citrated 

—  0.6 

monobrom 

—  0.3 

salicylated 

—  0.3 

valerianated        

—  0.3 

Cannabin  tannate 

—  1. 

Cannabindon  

—  0.06 

Cannabinon 

—  0.1 

Cantharidin 

34 

Capsicin          

—  0.015 

Capsicum        

—  0.3 

Carniferrin     .       

—  0.5 

Cellotropin            

—  0.5 

Cerberin     .            

25—0.001 

Cerium  nitrate     

—  0.2 

oxalate         

—  0.3 

Cerolin           

—  0.6 

Cetrarin             

—  0.2 

Charcoal     

—  2. 

Chelidonin   phosphate 

—  0.2 

sulphate 

—  0.2 

tannate     

Chelidonium   

—  2. 

Chelonin 

—  0.1 

—  2.5 

Chimaphilin 

—  0.25 

Chimaphenin        

—  0.6 

Chionanthin          

—  0.2 

—  2. 

Chloralamid       

—  3. 

—  2. 

Chloralbacid 

—  1. 

—  0.4 

subcut. 

612 


APPENDIX 


Remedy 


Grains  or  minims 


Chloralformamid. . 
Chloral  hydrate . . . 

Chloralimid 

Chloralose 

Chloral-urethane.. 

Chloretone 

Chlorin  water.  . . . 

Chlorobrom 

Chlorodyne 

Chloroform 

Chloropepsoid 

Chrysarobin 

Cimicifuga 

Cimicifugin 

Cinchona 

Clnchonidin 

Cinchonin 

iodosulphate . 

Cinnamon 

Cinnamyl-eugenol . 


Citarin 

Citrophen 

CitruUin " .••.••• 

Cobalt  and  potassium  nitrite. 
Cocain  carbolate 

hy  drochlorid 

Codein 

phosphate 


Colchicein 

Colchicin 

salicylate 

Collargol 

CoUinsonin 

Colocynth 

Colocynthin 

Columbin 

Condurangin 

Coniin  hydrobrom. 

Contradolin 

Convallamarin 

Convallarin 

Convolvulin 

Copaiva 

Copper,  acetate. . . 

arsenite 


nitrate 

oxid,  black 

phosphate 

sulphate 

emetic 

and  ammonium  sulphid. 

Cordol 

Coriamyrthin 


15—45 
10—30 
15—30 

3—12 
10—45 

6—20 
60—240 
60—120 

5—20 

2—5 
60—120 

5—30 
V2— 2 

5—15 

1—2 

1—2 

1—5 
10—30 

2—8 
subcut. 
15—30 

8—15 
Ve— V» 

'U—'U 

V2— IV2 
V2— 2 
V2-I 
subcut. 
'/120— Veo 
V120 — V30 
Vso 
1—3 
2—4 
3—10 
Ve— V3 
V2-I 
Vio— V4 
Veo— Vi5 
4—8 
V2-I 
2—4 
1—3 
20—60 
Vs— V4 
V120  every 
V2  hour 

V.2— V6 

Vi— IV2 

Vs— V2 

V«-V3 

2—5 

V2-2 

15—30 


Grams  or  C.c. 


1. 

0.6 

1. 

0.2 

0.6 

0.4 

4. 

4. 

0.3 

0.13 

4. 

0.008 

0.3 

0.03 

0.3 

0.06 

0.06 

0.6 

0.6 

0.13 


-  3. 

-  2. 
2. 

-  0.8 

-  3. 

-  1.3 
-15. 

-  8. 

-  1.3 

-  0.3 


0.015 
2. 

0.13 
1. 

0.13 
0.13 
0.3 
2. 
0.5 
subcut. 
—  2. 


1. 

0.5 

0.01 

0.015 

0.005 

0.03 

0.03 

0.03 

subcut. 
0.0005  —  0.001 
0.0005  — 
0.00075 
0.06       — 


1. 

0.02 

0.03 

0.01 

0.1 

0.13 

0.06 


0.002 


0.13 

0.2 

0.01 

0.03 

0.006 

0.001 

0.25 

0.03 

0.13 

0.06 

1.3 

0.008 


0.2 

0.25 

0.6 

0.04 

0.06 

0.015 

0.004 

0.5 

0.06 

0.25 

0.2 

4. 

0.015 


0.005  every  V 

hour 
0.005 


0.05 

0.008 

0.01 

0.13 

0.03 

1. 


0.01 

0.01 

0.03 

0.02 

0.3 

0.13 

2. 

0.001 


DOSE   TABLE 


613 


Remedy 


Cornin 

Cornutin  citrate 

Coronillin 

Cosaprin 

Cotarnin  hydrochlorid  (stypticin) 

Cotoin 

Creatin 

Greatinin 

Creolin 

Creosotal 

Creosote 

carbonate 

phosphate 

phosphite 

valerianate 

Cresol,  meta 

Cubebs 

Cupro-hemol 

Curare 

Curarin 

Cypripedin 

Cystogen 

Cytisin  hydrochlorid 

Damaianin 

Daturin 

Delphinin 

Dermatol 

Diaphtherin 

Diastase 

taka 

Diathesin 

Diethylketone 

Digalen 

Digitalein 

Digitalin,  French 

German 

Digitalis 

Digitoxin 

Dionin 

Dioscorein 

Diosmal 

Dithion 

Diuretin 

Dormiol 

Dover's  powder 

Duboisine  sulphate 

Duotal  (carbonate) 

Eigon,  beta 

alpha-sodium 

Elaterin 

Elaterium 

Emetin  alkaloid 

emetic 

Emulsion,  ammoniac 


Grains  or  minims 


2—4 

V20— Vs 

10 
5—15 

V4— 4 
2—3 
1—2 
1—2 
2—15 

20—80 
1—15 

15—30 

15—30 
1—15 
3—10 
1—3 
15—60 
3—6 

V12— Ve 

Veo— V12 
1—3 
5 

.V24— V.2 


2—5 


V2 


V260' 

Veo- 

4—8 

8—15 

1—3 

3—5 

8—15 

8—15 

^/200 
V64— Vl. 

V250— Ve^ 

V.o— V2 

1—3 

V26O— Vi: 
V4-I 

1—4 

2—10 

3—15 

15 
8—30 
5—20 

V80— V2, 
4—15 


15—45 
15—45 

V20 — V12 

V8— V2 

V120— Vso 

V.6— Vs 

240—480 


Grams  or  C.c. 


0.13  — 

0.003  — 
0.6  daily 

0.3  — 

0.05  — 

0.13  — 

0.06  — 

0.06  — 

0.13  — 

1.25  — 

0.06  — 

1.  — 

1.  — 

0.06  — 

0.2  — 

0.6  — 

1.  — 

0.2  — 

0.005  — 

0.001  — 

0.06  — 
0.3 

0.0025  — 

0.13  — 
0.00025— 

0.001  — 

0.25  — 

0.5  — 

0.06  — 

0.2  — 

0.5  — 

0.5  — 
0.0003 

0.001  — 
0.00025— 

0.006  — 

0.06  — 
0.00025— 

0.015  — 

0.06  — 

0.12  — 

0.2  — 
1. 

0.5  — 

0.3  — 

0.0008  — 

0.25  — 


0.25 
0.008 

1.    . 

0.25 

0.2 

0.13 

0.13 

1. 

5. 

1. 

2. 

2. 

1. 

0.6 

0.2 

4. 

0.4 

0.01 

0.005 

0.2 

0.005 

0.3 

0.001 

0.003 

0.5 

1. 

0.2 

0.3 

1. 

1. 

0.004 

0.001 

0.03 

0.2 

0.0005 

0.06 

0.25 

0.6 

1. 

2. 
1.3 

0.003  . 
1. 


1.  —  3. 

1.  —  3. 

0.003  —  0.005 

0.008  —  0.03 

0.0005  —  0.001 

0.004  —  0.008 

15.  —30. 


614 


APPENDIX 


Remedy 


Emulsion,  asafetida 

chloroform 

Enesol 

Enterin 

Ergot 

Ergotin,  bombelon 

bonjean 

Erythrol  tetranitrid 

Ery throphlein  hydrochlorid 

Erythroxylin 

Eserin  salicylate 

Ether 

ozonized 

petroleum 

valerianic 

Ethyl  bromid 

formate 

iodid 

valerianate 

Ethylen  bromid 

Eucalyptol 

Eudoxin 

Eugenoform 

Eugenol 

Eunatron 

Eumenol 

Eumydrin 

Eunatrol 

Euonymin 

Eupatorin 

Euphorbin 

Euphorin 

Eupurpurin 

Eupyrin 

Euquinin 

Europhen 

Exalgin 

Exodin 

Extract,  absinth.,  alcoholic 

absinth.,  fluid 

achillea,  alcoholic 

fluid 

aconite 

fluid 

adhatoda,  fluid 

adonis  root,  fluid 

vern.,  aqueous 

aesculus,  glab.,  fluid 

hippocast.  bark,  fluid 

seeds,  fluid 

agrimonia,  fluid 

aletris,  alcoholic 

fluid 

allium,  fluid 

aloes 

*2}^ — 5  fluidrams  (10 — 20C.C.)  as  inhalation  anesthetic 


Grains  or  minims 


120—360 

60—120 

Ve 

5—15 

20—90 

30—90 

3—10 

V2— 1 

V32— Vl6 

V4-I 

*/l20 VsO 

10—40 
30—60 

2—10 

1—2 
*5— 10 
60—120 

5—15 

1—2 

1—2 

4—12 

5—15 

5—15 

8—30 

4—8 
60 

Veo— V24 
10—15 
Vh—6 

1—3 
V4— 3 

8—15 

1—4 
15—30 
V2-2 
V2— IV2 

2—5 
15—45 

5—20 
20—60 

5—20 
30—60 
V4— V2 

V/4— 1 

15—60 
V2— 5 
Ve-l 
10—20 
20—60 
10—30 
20—60 
V2— 3 
30—60 
30—60 
1—6 


Grams  or  C.c. 


4. 

0.01 

0.3 

1.3 

2. 

0.2 

0.03 

0.002 

0.015 

0.0005 

0.6 

2. 

0.12 

0.06 

0.3 

4. 

0.3 

0.06 

0.06 

0.25 

0.3 

0.3 

0.5 

0.25 

4. 

0.001 

0.6 

0.1 

0.06 

0.015 

0.5 

0.06 

1. 

0.03 

0.03 

0.13 

1. 

0.3 

1.3 

0.3 

2, 

0.015 

0.015 

1. 

0.03 

0.01 

0.6 

1.3 

0.6 

1.3 

0.03 

2. 

2. 

0.06 


-24. 


1. 

6. 

6. 

0.6 

0.06 

0.004 

0.06 

0.002 

2.5 

4. 

0.6 

0.12 

0.6 

8. 

1. 

0.13 

0.13 

0.8 

1. 

1. 

2. 

0.5 

0.0025 

1. 

0.4 

0.02 

0.2 

1. 

0.25 

2. 

0.13 

0.1 

0.3 

3. 

1.3 

4. 

1.3 

4. 

0.03 

0.06 

4. 

0.3 

0.06 

1.3 

4. 

2. 

4. 

0.2 

4. 

4. 

0.4 


DOSE   TABLE 


615 


Remedy 


Extract,  aloes,  fluid 

alstonia,  fluid 

althea,  fluid 

alnus  serrul.,  fluid 

ampelopsis,  fluid 

anemone  hepat.,  fluid 

angelica  root,  fluid 

seed,  fluid 

anise,  fluid 

anthemis,  aqueous 

fluid 

apium,  alcoholic 

fluid 

aplopappus,  fluid 

apocynum,  fluid 

androsaemifol,  fluid 

cannab,  alcoholic 

apple,  ferrated 

aralia,  hisp.,  fluid 

racem.,  fluid 

arctostaph,  glauca,  fluid .  . .  . 

areca,  fluid 

ailanthus,  fluid 

arnica  flowers 

fluid 

arnica  root 

fluid 

artemis,  abrotan,  fluid 

frig.,  fluid 

vulg 

fluid 

asaf etida,  fluid 

asarum,  fluid 

ascep.  syriaca,  fluid 

curassav.,  fluid 

incarn.,  fluid 

asparagus,  fluid 

aspidium,  fluid 

aspidosperma,  fluid. 

aurant,  amar.,  alcoholic 

baptisia,  fluid . 

belladonna,  leaves,  alcoholic 

aqueous,  dry 

fluid 

berberis,  aquif.,  alcoholic... 

fluid 

vulg.,  fluid 

blackberry,  aqueous 

fluid 

black  haw,  fluid 

boldo,  fluid 

borage,  fluid 

brunfelsia,  fluid 

bryonia,  alcoholic 

fluid 

buchu,  alcoholic 


Grains  or  minims 


10—30 
30—60 
30—60 
30—60 

5—20 
30—60 
30—60 
30—60 
30—60 

3—15 
30—60 
10—20 
60—120 

8—15 

5—20 

5—30 

1—4 

3—15 
30—60 
30—60 
20—60 
45—120 
10—30 

3—10 

5—30 

1—2 

5—10 
30—60 
60—120 

2-10 
30—60 

5—20 
15—60 
30—60 
60—120 
30—60 
30—60 
60—240 
30—60 

2—10 
10—60 
Vs— 'A 
V4-I 

2—6 

2—6 
10—30 
30—60 

5—10 
30—60 
30—60 

4—8 
30—60 

5—20 

2—6 
20—60 

5—10 


Grams  or  C.c. 


0.6 

2. 

2. 

2. 

0.3 

2. 

2. 

2. 

2. 

0.2 

2. 

0.6 

4. 

0.5 

0.3 

0.3 

0.06 

0.2 

2. 

2. 

1.3 

3. 

0.6 

0.2 

0.3 

0.06 

0.3 

2. 

4. 

0.13 

2. 

0.3 

1. 

2. 

4. 

2. 

2. 

4. 

2. 

0.13 

0.6 

0.008 

0.015 

0.13 

0.13 

0.6 

2. 

0.3 

2. 

2. 

0.25 

2. 

0.3 

0.13 

1.3 

0.3 


—  1.3 


2. 
4. 
4. 
4. 
1. 

-  4. 

-  4. 

-  4. 

-  4. 

-  1. 

-  4. 

-  1.3 

-  8. 

-  1. 

-  1.3 

-  2. 

-  0.25 

-  1. 

-  4. 

-  4. 

-  4. 

-  8. 

-  2. 

-  0.6 

-  2. 

-  0.13 

-  0.6 

-  4. 

-  8. 

-  0.6 

-  4. 

-  1.3 

-  4. 

-  4. 

-  8. 

-  4. 

-  4. 
-15. 

-  4. 

-  0.6 

-  4. 

-  0.03 

-  0.06 

-  0.4 

-  0.4 
2. 

-  4. 

-  0.6 

-  4. 

-  4. 

-  0.5 

-  4. 

-  1.3 

-  0.4 

-  4. 

-  0.6 


616 


APPENDIX 


Remedy 


Extract,  buchu,  alcoholic,  fluid  . . 

comp 

buckthorn  berries,  fluid 

burdock,  fluid 

calamus,  dry 

fluid 

calendula,  alcoholic 

fluid 

calumba,  alcoholic 

dry 

fluid 

calycanthus,  fluid 

canella,  fluid 

cannab.  indicus 

fluid 

capsella,  fluid 

capsicum 

fluid 

caraway,  fluid 

cardenia,  aqueous,  dry 

fluid 

carthamus,  fluid 

carum  copt.,  fluid 

caryoph,  fluid 

cascara,  amarga 

sagr 

fluid 

cascarilla,  alcoholic 

fluid 

castanea,  fluid 

catechu,  aqueous,  dry 

fluid 

caulophyllum,  alcoholic 

fluid 

celastrus,  fluid 

cephalanthus,  fluid 

cercis,  fluid 

cereus  grandiflora,  fluid 

chamaelirium,  fluid 

chelidonium,  alcoholic 

fluid 

chenopodium,  fluid 

chimaphila,  fluid 

chionanthus 

fluid 

chirata,  fluid 

chrysanthemum,  fluid 

chrysophyllum,  aqueous,  dry 

cicorium 

cicuta,  fluid 

cimicifuga 

fluid 

cinchona 

fluid 

cinch,  calls.,  alcoholic,  dry... 
cinnamon,  fluid 


Grains  or  minims 

Grams  or  C.c. 

15—30 

1. 

—  4. 

20—60 

1.3 

—  4. 

30—60 

2, 

—  4. 

30—60 

2. 

—  4. 

2—6 

0.13 

—  0.4 

15—60 

1. 

—  4. 

2—6 

0.13 

—  0.4 

15     60 

1. 

—  4. 

4—20 

0.25 

—  1.3 

2—10 

0.13 

—  0.6 

5—20 

0.3 

—  1.3 

30—60 

2. 

—  4. 

15—60 

1. 

—  4. 

V4— 1 

0.015 

—  0.06 

2—5 

0.13 

—  0.3 

15—150 

1. 

—10. 

V.O— V2 

0.006 

—  0.03 

1—5 

0.06 

—  0.3 

30—60 

2. 

—  4. 

5—10 

0.3 

—  0.6 

30—60 

2. 

—  4. 

16—60 

1. 

—  4. 

10—30 

0.6 

—  2. 

5—10 

0.3 

—  0.6 

30—60 

2. 

—  4. 

5—20 

0.3 

—  1.3 

15—60 

1. 

—  4. 

2—6 

0.13 

—  0.4 

15—45 

1. 

—  3. 

60—120 

4. 

—  8. 

5—20 

0.3 

—  1.3 

30—120 

2. 

—  8. 

2—5 

0.13 

—  0.3 

10—30 

0.6 

—  2. 

30—60 

2. 

—  4. 

30—60 

2. 

—  4. 

15—60 

1. 

—  4. 

3—10 

0.2 

—  0.6 

30—60 

2. 

—  4. 

5—20 

0.3 

—  1.3 

15—60 

1. 

—  4. 

30—60 

2. 

—  4. 

30—60 

2. 

—  4. 

3—10 

0.2 

—  0.6 

30—60 

2. 

—  4. 

10—30 

0.6 

—  2. 

30—60 

2. 

—  4. 

2—5 

0.13 

—  0.3 

20—40 

1.3 

—  2.5 

1—5 

0.06 

—  0.3 

2—6 

0.13 

—  0.4 

15—45 

1. 

—  3. 

1—10 

0.06 

—  0.6 

5—15 

0.3 

—  1. 

2—5 

0.13 

—  0.3 

10—30 

0.6 

2 

DOSE   TABLE 


617 


Remedy 


Extract,  citrullus  valg.,  fluid 
coca,  alcoholic,  dry 

fluid 

cochlearia,  fluid 

officio 

coffee  (green),  alcoholic. 

(green),  fluid 

(roasted),  fluid 

cola,  alcoholic,  dry 

fluid 

colchicum  seed,  acetic. . 

fluid 

collinsonia 

fluid 

colocynth 

compound 

fluid 

conium 

fluid 

leaves,  fluid 

convallaria,  alcoholic . . . 

fluid 

flowers,  fluid 

corallorhiza,  fluid 

coriander,  fluid 

cornus  flor 

fluid 

coto 

crocus,  alcoholic 

cubeb 

fluid 

curcuma,  alcoholic 

fluid 

cusparia,  fluid 

cynoglossum,  aqueous. . 

fluid 

cyperus,  fluid 

cypripedium 

fluid 

delphin,  consolida,  fluid, 
digitalis 

alcoholic,  dry 

fluid 

dioscorea,  fluid 

diospyros,  fluid 

drosera 

fluid 

duboisia 

fluid 

dulcamara,  alcoholic. . . . 

fluid 

echinacea,  fluid 

elephantopus,  fluid 

embelia,  fluid 

ephedra,  fluid 

epifagus,  fluid 


Grains  or  minims 


60—120 

4—15 
20—60 
30—60 

8—30 

3—10 
20—60 
20—60 

2—5 
15—60 

1—3 

3—10 

4—10 
20—60 

1—3 

3—10 

5—10 
V2— 2 

2—5 

2—5 

1—4 
15—30 

5—15 
30—60 
20—60 

5—10 
30—60 

5—15 

2—6 

2—10 
15—60 

1—5 
10—30 
10—30 

1—5 
10—30 
10—30 

2—5 
15—30 

1—5 
V4— V2 
V«— 1 

1—3 

15—60 

30—60 

1—3 

5—20 

V4-I 

5—10 

5—20 

30—120 

30—60 

5—30 

60—240 

60—120 

30—60 


Grams  or  C.c. 


4. 

0.25 

1.3 

2. 

0.5 

0.2 

1.3 

1.3 

0.13 

1. 

0.06 

0.2 

0.25 

1.3 

0.06 

0.2 

0.3 

0.03 

0.13 

0.13 

0.06 

1. 

0.3 

2. 

1.3 

0.3 

2. 

0.3 

0.13 

0.13 

1. 

0.06 

0.6 

0.6 

0.06 

0.6 

0.6 

0.13 

1. 

0.06 

0.015 

0.01 

0.06 

1. 

2. 

0.06 

0.3 

0.015 

0.3 

0.3 

2. 

2. 

0.3 

4. 

4. 

2. 


-  1. 

-  4. 

-  4. 

-  2. 

-  0.6 

-  4. 

-  4. 

-  0.3 

-  4. 

-  0.2 

-  0.6 

-  0.6 

-  4. 

-  0.2 

-  0.6 

-  O.H 

-  0.1 

-  0.3 

-  0.3 

-  0.25 

-  2. 

-  1. 

-  4. 

-  4. 

-  0.6 

-  4. 

-  1. 

-  0.4 

-  0.6 

-  4. 

-  0.3 

-  2. 

-  2. 

-  0.3 

-  2. 

-  2. 

-  0.3 

-  2. 

-  0.3 

-  0.03 

-  0.06 

-  0.2 

-  4. 

-  4. 

-  0.2 

-  1.3 

-  0.06 

-  0.6 

-  1.3 

-  8. 

-  4. 

-  2. 
-15. 

-  8. 

-  4. 


618 


APPENDIX 


Remedy 


Extract,  epigaea,  fluid 

epilobium,  fluid 

equisetum,  fluid 

ergot 

fluid 

erigeron,  fluid 

eriodictyon,  fluid 

alcoholic 

erythraea,  aqueous 

erythrophleum,  fluid .... 
eucalyptus,  alcoholic,  drj^ 

fluid 

seed,  alcoholic 

fluid 

euonymus 

fluid 

eupatorium,  fluid 

eupator,  perfol 

eupator.  purpur 

fluid 

euphorb.  coroll,  fluid. .  . . 
euphorb.  pilulif.,  fluid.  . . 

fennel,  fluid 

frangula,  aqueous,  dry. . . 

fluid 

frankenia,  fluid 

fraximus  americ,  fluid. . . 
frax.  sambucif.,  fluid.  . .  . 
fucus,  dry 

fluid 

fumaria,  aqueous 

galega,  aqueous 

galium  aparine,  fluid.  . .  . 

galium  ver.,  fluid 

garcinia 

fluid 

gaultheria,  fluid 

gelsemium,  alcoholic,  dry 

fluid 

gentian 

fluid 

gentian,  fluid,  co 

quinquefl.,  fluid 

geranium 

fluid 

gossypium,  alcoholic,  dry 

fluid 

gouania,  fluid 

granatum,  alcoholic,  dry. 

(tenif  uge) 

fluid 

(tenifuge) 

grindelia,  aqueous 

fluid 

guaco,  fluid 

guaiac 


Grains  or  minims 

Grams  or  C.c. 

30—60 

2. 

—  4. 

30—60 

2. 

—  4. 

30—60 

2. 

—  4. 

5—15 

0.3 

—  1. 

30—120 

2. 

—  8. 

30—60 

2. 

—  4. 

20—60 

1.3 

—  4. 

4—12 

0.25 

—  0.8 

5—30 

0.3 

—  2. 

5—15 

0.3 

—  1. 

1—3 

0.06 

—  0.2 

5—20 

0.3 

—  1.3 

10—40 

0.6 

—  2.5 

60—240 

4. 

—15. 

2—5 

0.13 

—  0.3 

15—60 

1. 

—  4. 

20—60 

1.3 

—  4. 

4—10 

0.25 

—  0.6 

5—10 

0.3 

—  0.6 

30—60 

2. 

—  4. 

5—30 

0.3 

—  2. 

30—60 

2. 

—  4. 

30—60 

2. 

—  4.      • 

3—10 

0.2 

—  0.6 

15—30 

1. 

—  2. 

10—20 

0.6 

—  1.3 

20—40 

1.3 

—  2.5 

30—60 

2. 

—  4. 

1—5 

0.06 

—  0.3 

10—30 

0.6 

—  2. 

10—60 

0.6 

—  4. 

8—15 

0.5 

—  1. 

30—60 

2. 

—  4. 

30—60 

2. 

—  4. 

1—2 

0.06 

—  0.13 

15—60 

1. 

—  4. 

30—60 

2. 

—  4. 

y^—Vi 

0.015 

—  0.03 

2—5 

0.13 

—  0.3 

2—6 

0.13 

—  0.4 

10—30 

0.6 

—  2. 

10—30 

0.6 

—  2. 

30—60 

2. 

—  4. 

5—10 

0.3 

—  0.6 

30—60 

2. 

—  4. 

3—10 

0.2 

—  0.6 

30—60 

2. 

—  4. 

60—120 

4. 

—  8. 

5—10 

0.3 

—  0.6 

30—90 

2. 

—  6. 

15—60 

1. 

—  4. 

240—720 

15. 

—45. 

3—10 

0.2 

—  0.6 

20—60 

1.3 

—  4. 

30—60 

2. 

—  4. 

3—10 

0.2 

—  0.6 

DOSE   TABLE 


619 


Remedy 


Grains  or  minims 


Extract,  guaiac,  fluid 

guarana,  dry 

fluid 

hamamelis,  alcoholic,  dry 

fluid 

hedeoma,  fluid 

helianth,  fluid 

hellebor,  niger 

niger,  fluid 

vir 

hematoxylon 

humulus,  fluid 

alcoholic 

aqueous 

hydrangea,  fluid 

hydrastis 

fluid 

hyoscyamus 

leaves 

seed,  dry 

fluid 

ignatia,  alcoholic,  dry . . . 

fluid 

iris 

fluid 

jaborandi,  fluid 

jalap 

kamala,  fluid 

kava-kava 

fluid 

kino,  fluid 

kousso,  alcoholic 

fluid 

krameria 

alcoholic 

fluid 

lactucarium 

lactuca,  alcoholic 

lactuc,  can 

lactucar,  fluid 

lappa,  alcoholic 

fluid 

leptandra 

fluid 

levisticum,  fluid 

lobelia 

fluid 

seed,  fluid 

lupulin,  fluid 

lycop,  europ.j  fluid 

magnolia,  fluid 

male  fern  =oleores 

malt 

dry 

marrubium 

fluid 


30—120 

2—5 
15—60 

3—10 
15—60 
15—60 
30—60 

30—60 

2—5 
10—20 
30—60 

2—5 

4—10 
30—60 

3—10 
10—30 

1—3 

1—2 
V2-I 

5—15 

V8— V2 

1—4 

2—6 
10—30 
10—30 

2—5 
60—120 

3—10 
15—60 
10—30 
30—60 
60—240 

2—10 

5—15 
15—60 

2—10 
V2— 2 
10—30 
10—60 

4—8 
30—60 

3—10 
20—60 
15—60 
V2-2 

2—10 

2—10 
10—20 
30—60 
30—60 
1  0—240 
240 
60—240 

3—10 
30—120 


Grams  or  C.c. 


2. 

0.13 
1. 
0.2 
1. 
1. 
2. 

0.03 
2. 

0.13 
0.6 
2. 

0.13 
0.25 
2. 
0.2 
0.6 
0.06 
0.06 
0.03 
0.3 
0.008 
0.06 
0.13 
0.6 
0.6 
0.13 
4. 
0.2 
1. 
0.6 
2. 
4. 

0.13 
0.3 
1. 

0.13 
0.03 
0.6 
0.6 
0.25 
2. 
0.2 
1.3 
1. 

0.03 
0.13 
0.13 
0.6 
2. 
2. 
8. 
15. 
4. 
0.2 
•2 


-  0.3 

-  4. 

-  0.6 

-  4. 

-  4. 

-  4. 

-  0.1 

-  4. 

-  0.3 

-  1.3 

-  4. 

-  0.3 

-  0.6 

-  4. 

-  0.6 

-  2. 

-  0.2 

-  0.13 

-  0.06 

-  1. 

-  0.3 
0.25 

-  0.4 
2. 

-  2. 

-  0.3 

-  8. 

-  0.6 

-  4. 

-  2. 

-  4. 
-15. 

-  0.6 

-  1. 

-  4. 

-  0.6 

-  0.13 

-  2. 

-  4. 

-  0.5 

-  4. 

-  0.6 

-  4. 

-  4. 

-  0.13 

-  0.6 

-  0.6 

-  1.3 

-  4. 

-  4. 
-15. 

-15. 

-  0.6 


620 


APPENDIX 


Remedy 


Extract,  matico,  alcoholic. . 

fluid 

matricaria,  alcoholic. . . 

fluid 

melia,  fluid 

melissa,  fluid 

menispermum,  fluid . . . 

mezereum,  dry 

michella,  fluid 

monarda,  fluid 

monesia 

myristica,  fluid 

myrrh,  fluid 

naregamia,  fluid 

nepeta,  fluid 

nicotiana,  alcoholic 

fluid 

nux  vomica 

fluid 

nymphas,  fluid 

Oenothera,  fluid 

opium 

aqueous 

papaver,  alcoholic 

fluid 

pareira,  fluid 

parsley,  root 

seed,  fluid 

passiflora,  fluid 

phellandrium,  alcoholic 
physostigma 

fluid 

Phytolacca  berries  .... 

root 

fluid 

pichi  (f abiana) 

fluid 

pilcarpus,  dry 

fluid 

pimentia,  fluid 

pimpinella 

fluid 

pinus  strob,  fluid 

pinus  sylvest 

piper  jabor,  fluid 

methyst 

nigra 

fluid 

podophyllum 

fluid 

polyporus,  fluid 

polytrichum,  fluid 

pomegran,  fluid 

populus  balsam. 

nigra 

prunus  virg.,  fluid 


Grains  or  minims 

Grams  or  C.c. 

5—10 

0.3 

—  0.6 

30—63 

2. 

—  4. 

2—8 

0.13 

—  0.5 

15—60 

1. 

—  4. 

10—30 

0.6 

—  2. 

60—120 

4. 

—  8. 

30—60 

2. 

—  4. 

1—3 

0.06 

—  0.2 

30—60 

2. 

—  4. 

15—60 

1. 

—  4. 

2—5 

0.13 

—  0.3 

5—20 

0.3 

—  1.3 

10—30 

0.6 

—  2. 

1—2 

0.06 

—  0.13 

30—120 

2. 

—  8. 

Vio— 1 

0.006 

—  0.06 

Vi— 5 

0.03 

—  0.3 

Vs— V2 

0.008 

—  0.03 

1—5 

0.06 

—  0.3 

15—60 

1. 

—  4. 

30—60 

2. 

—  4. 

V4— 1 

0.015 

—  0.06 

V4— 1 

0.015 

—  0.06 

1—4 

0.06 

—  0.25 

10—30 

0.6 

—  2. 

30—60 

2. 

—  4. 

30—120 

2. 

—  8. 

30—60 

2. 

—  4. 

10—30 

0.6 

—  2. 

2—5 

0.13 

—  0.3 

Vl2— V4 

0.005 

—  0.015 

1—3 

0.06 

—  0.2 

5—15 

0.3 

—  1. 

V4— 1 

0.015 

—  0.06 

1—5 

0.06 

—  0.3 

3—12 

0.2 

—  0.8 

15—60 

1. 

—  4. 

2—5 

0.13 

—  0.3 

10—30 

0.6 

—  2. 

10—40 

0.6 

—  2.5 

5—15 

0.3 

—  1. 

20—60 

1.3 

—  4. 

30—60 

2. 

—  4. 

3—6 

0.2 

—  0.4 

10—30 

0.6 

—  2. 

3—10 

0.2 

—  0.6 

2—8 

0.13 

—  0.5 

10—40 

0.6 

—  2.5 

2—5 

0.13 

—  0.3 

10—30 

0.6 

—  2. 

2—15 

0.13 

—  1. 

20—60 

1.3 

—  4. 

60—120 

4. 

—  8. 

30—60 

2. 

—  4. 

3—10 

0.2 

—  0.6 

20—60 

1.3 

—  4. 

DOSE   TABLE 


621 


Remedy 


Grains  or  minims 


Extract,  ptelea,  fluid 

pulmonaria,  fluid 

Pulsatilla 

fluid 

pyrethrum 

pyrus,  fluid 

quassia,  alcoholic,  dry. . 

aqueous,  dry 

fluid 

quebracho,  dry 

quercus 

quillaja 

rhamnus,  cath.,  fluid. .  . 

frang 

pursh 

rhododendron,  fluid .... 
rhubarb 

(laxative) 

(purgative) 

fluid 

dry 

fluid,  arom. 

and  senna,  fluid 

rhus  arom.,  fluid 

glabra,  fluid. 

radicans,  fluid 

ricinus,  leaves 

seed,  fluid 

rose,  fluid 

rubia,  aqueous 

rubus,  fluid 

strig.,  fluid 

villos,  aqueous 

villos,  fluid 

rumex  acetos 

crisp 

crisp,  fluid 

uta,  alcoholic 

fluid 

sabadilla,  fluid . . .  . . 

sabbatia  angul.,  fluid. . . 

sage,  fluid 

salix  alb.,  fluid 

salix  nigr.  bark,  fluid. . . 

buds,  fluid 

sambucus,  fluid 

sanguinaria,  aqueous. .  . 

emetic 

fluid 

santonica,  alcoholic . . .  . 
saponaria,  alcoholic.  . .  . 

fluid 

sarsapar.j  alcoholic,  dry 

CO.,  fluid 

fluid 

sassafras,  aqueous 


15—30 
30—60 

V4— 1 

2—5 
30—60 
60—120 

1—5 

2—5 
10—30 

2—5 

3—10 

2—5 
30—60 

3—10 

5—20 
30—60 

1—3 

3—6 

6—10 

5—30 

1—10 
10—60 
30—60 
15—60 
30—60 

1—5 
30—60 
10—30 
30—60 

3—10 
30—60 
10—60 

5—10 
30—60 

5—10 

3—10 
15—60 

2—5 
15—30 

5—15 
30—60 
15—60 
30—60 

5—60 

30—60 

30—120 

'U—'h 

vh—s 

3—20 

2—5 

8—20 
40—120 

5—20 
30—120 
30—120 

2—8 


Grams  or  C.c. 


1. 

2. 

0.015 

0.13 

2. 

4. 

0.06 

0.13 

0.6 

0.13 

0.2 

0.13 

2. 

0.2 

0.3 

2. 

0.06 

0.2 

0.4 

0.3 

0.06 

0.6 

2. 

1. 

2. 

0.06 

2. 

0.6 

2. 

0.2 

2. 

0.6 

0.3 

2. 

0.3 

0.2 

1. 

0.13 

1. 

0.3 

2. 

1. 

2. 

0.3 

2. 

2. 

0.01 

0.1 

0.2 

0.13 

0.5 

2.5 

0.3 

2. 

2. 

0.13 


—  2. 

—  4. 

—  0.0 

—  0.3 

—  4. 

—  8. 

—  0.3 

—  0.3 

—  0.2 

—  0.3 

—  0.6 

—  0.3 

—  4. 

—  0.6 

—  1.3 

—  4. 

—  0.2 

—  0.4 

—  0.6 

—  2. 

—  0.6 

—  4. 

—  4. 

—  4. 

—  4. 

—  0.3 

—  4. 

—  2. 

—  4. 

—  0.6 

—  4. 

—  4. 

—  0.6 

—  4. 

—  0.6 

—  0.6 

—  4. 

—  0.3 

—  2. 

—  1. 

—  4. 

—  4. 

—  4. 

—  4. 

—  4. 

—  8. 

—  0.02 

—  0.2 

—  1.3 

—  0.3 

—  1.3 

—  8. 

—  1.3 

—  8. 

—  8. 

—  0.5 


622 


APPENDIX 


Remedy 


Extract,  sassafras,  fluid 

satureja,  fluid 

savine,  alcoholic 

fluid 

scoparius,  fluid 

scopolia,  fluid 

Scutellaria 

fluid 

senecio 

fluid 

senega,  alcoholic,  dry 

fluid 

senna,  alcoholic 

fluid 

serpentaria 

fluid 

sesamum,  fluid 

solidago  odor,  fluid 

solidago  virg.,  fluid 

sorghum,  fluid 

spigelia  co.,  fluid 

spigelia,  fluid 

spigelia  and  senna,  fluid 

spiraea,  fluid 

squill  CO.,  fluid 

squill,  fluid 

stachys,  fluid 

statice,  fluid 

stillingia 

fluid 

fluid  CO 

stramonium  leaves,  alcoholic,  dry 

fluid 

stramonium  seed 

fluid 

strophanthus 

fluid 

strychn.  malac,  fluid 

stylosanthes,  fluid 

sumbul 

fluid 

sycocarpus,  fluid 

Symphytum,  fluid 

symplocarpus,  fluid 

tansy,  fluid 

taraxacum 

fluid 

teucrium,  fluid 

thapsia,  fluid 

thuja,  fluid , 

thymus,  fluid 

tonga,  fluid 

tormentilla,  dry 

fluid 

trillium,  fluid 

triticum,  aqueous 


Grains  or  minims 


30—60 
30—60 
Va— 2 

5—20 
30—60 

1—3 

5—10 
30—60 

2—10 
10—60 

1—3 

5—20 
10—40 
60—240 

1—5 
10—30 

1—10 
30—60 
30—60 
30—60 
90—180 
60—120 
90—180 
30—60 

2—15 

1—3 
30—60 
10—30 

3—10 
15—60 
30—90 
'A-l 

1—3 

1—3 

V64— Vu 

10—30 
10—20 

2—5 
20—60 
10—30 
30—60 
10—20 
30—60 
10—30 
60—120 
30—60 

2—10 
30—60 

5—30 
10—30 

5—15 
30—60 
60—120 

8—30 


Grams  or  C.c. 


2. 

2. 

0.03 

0.3 

2. 

0.06 

0.3 

2. 

0.13 

0.6 

0.06 

0.3 

0.6 

4. 

0.06 

0.6 

0.06 

2. 

2. 

2. 

6. 

4. 

6. 

2. 

0.13 

0.06 

2. 

0.6 

0.2 

1. 

2. 

0.015 

0.06 

0.015 

0.06 

0.001 

0.008 

0.06 

0.6 

0.2 

1.3 

0.6 

2. 

0.6 

2. 

0.6 

4. 

2. 

0.13 

2. 

0.3 

0.6 

0.3 

2. 

4. 

0.5 


-  4. 

-  4. 

-  0.13 

-  1.3 

-  4. 

-  0.2 

-  0.6 

-  4. 

-  0.6 

-  4. 

-  0.2 

-  1.3 

-  2.5 
-15. 

-  0.3 

-  2. 

-  0.6 

-  4. 

-  4. 

-  4. 
12. 

-  8. 
12. 

-  4. 

-  1. 

-  0.2 

-  4. 

-  2. 

-  0.6 

-  4. 

-  6. 

-  0.06 

-  0.2 

-  0.03 

-  0.2 

-  0.004 

-  0.03 

-  2. 

-  1.3 

-  0.3 

-  4. 

-  2. 

-  4. 

-  1.3 

-  4. 

-  2. 
■  8. 

-  4. 
0.6 

-  4. 
2. 
2. 

-  1. 
4. 


—  2. 


DOSE   TABLE 


623 


Remedy 


Extract,  triticum,  aqueous,  fluid, 
turnera 

fluid 

tustilago,  fluid 

urechites,  fluid 

urtica,  fluid 

uva  ursi 

fluid 

vaccinium,  fluid 

valerian,  alcoholic 

fluid 

veratr.  vir 

fluid 

verbascum,  fluid 

verbena,  fluid 

viburn.  opul.,  fluid 

viburn.  prun.,  alcoholic,  dry 

fluid 

viola,  fluid 

wild  cherry,  fluid 

white  oak,  fluid 

xanthium  spin.,  fluid 

xanthium  strum.,  fluid 

xanthoxylum 

fluid 

berries,  fluid 

zea,  fluid 

Feralboid 

Ferratin 

Ferratogen 

Ferrinol 

Ferropyrin 

Ferrostyptin 

Fluoroformol  (fluorol) 

Formanilid 

Formin 

Fowler's  solution 

Fraserin 

Fuchsin 

Gaduol 

Gaiacophosphal 

Gallogen 

Galbanum 

Gall,  ox,  inspiss 

Gallobromol 

Gamboge 

Geissospermin 

Gelseminin 

Gentian 

Geosote 

Geraniin 

Gillenin 

Ginger 

Globon 


Grains  or  minims 


60—240 

5—20 
60—120 
30—60 

2—10 
15—30 

5—15 
60—120 
30—60 

5—15 
10—30 

V4— 1 

1—4 
30—60 
10—30 
30—60 

5—15 
15—60 
30—60 
20—60 
30—60 
60—120 
60—120 

5—10 
15—60 
20—10 
30—90 

V3— 1 

4—8 
5—8 
3—5 
5—15 
5—10 
240 
2—4 
8—15 
1—5 
1—3 
Va— 3 

5—30 
2—15 
5—15 

10—20 
2—5 

10—30 
1—5 
8—30 

Vl20 VsO 

10—30 
3—10 
1—3 
4—6 
5—20 

30—60 


Grams  or  C.c. 


4. 

0.3 

4. 

2. 

0.13 

1. 

0.3 

4. 

2. 

0.3 

0.6 

0.015 

0.06 

2. 

0.6 

2. 

0.3 

1. 

2. 

1.3 

2. 

4. 

4. 

0.3 

1. 

1.3 

2. 

0.02 
0.25 
0.3 
0.2 
0.3 
0.3 
15. 
0.13 
0.5 
0.06 
0.06 
0.03 

0.3 

0.13 

0.3 

0.6 

0.13 

0.6 

0.06 

0.5 

0.0005 

0.6 

0.2 

0.06 

0.25 

0.3 

2. 


-15. 

-  1.3 

-  8. 

-  4. 

-  0.6 

-  2. 

-  1. 

-  8. 

-  4. 

-  1. 

-  2. 

-  0.06 

-  0.25 

-  4. 

-  2. 

-  4. 

-  1. 

-  4. 

-  4. 

-  4. 

-  4. 


0.6 
4. 
2.5 
6. 

0.06 

0.5 

0.5 

0.3 

1. 

0.6 

0.25 

1. 

0.3 

0.2 

0.2 

2. 

1. 

1. 

1.3 

0.3 

2. 

0.3 

2. 

0.002 

2. 

0.6 

0.2 

0.4 

1.3 

4. 


624 


APPENDIX 


Remedy 


Gluside 

Glycerin 

Glycerite,  acid  carbolic 

acid  gallic 

acid  tannic 

tar 

Glycogenol 

Glycyrrhizin , 

Gold  and  potassium  bromid 

and  sodium  chlorid. . . . 

arsenite 

bromid 

cyanid 

chlorid 

iodid , 

oxid 

and  sod.  brom , 

Gomenol 

Gonosan . .  , 

Gossypiin 

Griserin 

Guaiac , 

Guaiacetin 

Guaiacol 

phosphate 

Guaiacyl 

Guaiamar 

Guaiaquin 

Guaiperol 

Guaranin 

Guarana 

Guethol 

Gujasanol 

Hamamelin 

Hashishin 

Hedonol 

Helenin 

Helicina 

Heliotropin 

Helleborein 

Helonin 

Helmitol 

Hemalbumin 

Hemogallol 

Hemoglobin 

Hemol 

Heparaden 

Heroin 

hydrochlorid 

Hetralin 

Histosan 

Hopagan 

Hydracetin 

Hydragogin 

Hydrastin 


Grains  or  mmims 

Grams  or  C.c. 

1—5 

0.06 

—  0.3 

60—240 

4. 

—15. 

5—20 

0.3 

—  1.3 

20—60 

1.3 

—  4. 

20—60 

1.3 

—  4. 

60—120 

4. 

—  8. 

5—10 

0.3 

—  0.6 

5—15 

0.3 

—  1. 

Ve— V3 

0.001 

—  0.04 

V24— Ve 

0.0025 

—  0.01 

V64— V12 

0.001 

—  0.005 

V20— Vs 

0.003 

—  0.012 

V2a— Vio 

0.003 

—  0.006 

Vso— Vl5 

0.0012 

—  0.004 

V64— Vs 

0.001 

—  0.008 

V20— V4 

0.003 

—  0.015 

Vs— V2 

0.008 

—  0.03 

4—8 

0.25 

—  0.5 

5—15 

0.3 

—  1. 

1—5 

0.06 

—  0.3 

5—8 

0.3 

—  0.5 

5—15 

0.3 

—  1. 

8—30 

0.5 

—  2. 

2—15 

0.13 

—  1. 

5—10 

0.3 

—  0.6 

V2— IV2 

0.03 

—  0.1 

3—15 

0.2 

—  1. 

5—10 

0.3 

—  0.6 

10—30 

0.6 

—  2. 

1—5 

0.06 

—  0.3 

15—60 

1. 

—  4. 

5—10 

0.3 

—  0.6 

15—30 

1. 

—  2. 

1—3 

0.06 

—  2. 

V4  daily 

0.05  daily 

15—30 

1. 

—  2. 

Ve— V2 

0.01 

—  0.03 

2—10 

0.12 

—  0.6 

15 

1. 

Ve— V3 

0.01 

—  0.02 

2—5 

0.13 

—  0.3 

15 

1. 

15—30 

1. 

—  2. 

4—8 

0.25 

—  0.5 

20—40 

1.25 

—  2.5 

2—8 

0.13 

—  0.5 

30 

2. 

V12— Ve 

0.005 

—  0.01 

V.2— Ve 

0.005 

—  0.01 

8—24 

0.5 

—15. 

60—240 

4. 

—15. 

2—7 

0.12 

—  0.4 

V4— 1 

0.015 

—  0.06 

8—15 

0.5 

—  1. 

V4-I 

0.015 

—  0.06 

DOSE   TABLE 


625 


Remedy 


Hydrohydrastinin 

Hydroquinon 

Hyoscin 

Hyoscyamin,  amorph. 

cryst 

Hypnacetin 

Hypnal 

Hypnon 


Ichthalbin 

Ichthof  orm 

Ichthyol 

Infus.  digitalis 

Ingluvin 

Inulin 

lodalbacid 

lodantipyrin 

lodgelatin 

lodin 

trichlorid 

vasogen 

lodipin,  10  per  cent, 
lodipin,  25  per  cent. 

lodocaffein 

Iodoform 

lodoformogen 

lodohemol 

lodol 

lodomuth 

lodophenin 

lodopyrin 

lodosin 

lodothein 

lodotheobromin 

lodothyrin 

lodovasogen 

Ipecac. 

emetic 

I  quinin 

Iridin 

Irisin 

Iron,  acetate 

albuminate,  dry . 

pepton 

sacch 

alginate 

arsenate 

benzoate 

bromid,  ferric . .  . 
ferric,  sacch . . 
ferrous , 

bromo-iodid 

cacodylate 

camphorate 

carbonate 


Grains  or  minims 


V4— V2 

5—15 

V200 — Vioo 
Vs— V4 

Vl28 V32 

3—5 

15—30 

2—5 

10—30 
8—20 
3—15 

60—240 
5—10 
1—3 

15—30 

10—30 
60 

V4-I 

4—6 

60—240 

30—120 

5—10 

1—3 

5—20 

3—10 

5—15 

1—10 

2—8 

5—20 

2—10 

2—8 

5—10 

5—15 

8—20 

V2— 1 

10—20 

2—10 

1—3 

2—4 

3—10 

3—10 

5—15 

5—20 

10—15 

V..— Vs 

1—3 

V3-I 

3—15 

1—5 

V2— 2 

1—5 

1—3 

5—15 


Grams  or  C.c. 


0.015 

0.3 

0.0003 

0.008 

0.0005 

0.2 

1. 

0.13 

1. 

0.5 

0.2 

4. 

0.3 

0.06 

1. 

0.6 

4. 

0.015 

0.004 

0.25 

4. 

2. 

0.3 

0.06 

0.3 

0.2 

0.3 

0.06 

0.12 

0.3 

0.13 

0.13 

0.3 

0.3 

0.5 

0.03 

0.6 

0.13 

0.06 

0.13 

0.2 

0.2 

0.3 

0.3 

0.6 

0.004 

0.06 

0.02 

0.2 

0.06 

0.03 

0.06 

0.06 

0.3 


-  0.03 

-  1. 

-  0.0006 

-  0.015 

-  0.002 

-  0.3 

-  2. 

-  0.3 

-  2. 

-  1.3 

-  1. 
-15. 

-  0.6 

-  0.2 

-  2. 

-  2. 

-  0.06 

-  0.012 

-  0.4 
-15. 

-  8. 

-  0.6 

-  0.2 

-  1.3 

-  0.6 

-  1. 

-  0.6 

-  0.5 

-  1.3 

-  0.6 

-  0.5 

-  0.6 

-  1. 

-  1.3 

-  0.06 

-  1.3 

-  0.6 

-  0.2 

-  0.25 

-  0.6 

-  0.6 

-  1. 

-  1.3 

-  1. 

-  0.008 

-  0.2 

-  0.06 

-  1. 

-  0.3 

-  0.13 

-  0.3 

-  0.2 

-  1. 


♦in  the  insane  '/»j  grain  (0.002  Gm.)  cautiously  increased  until  effect  is  produced. 


626 


APPENDIX 


Remedy 


Iron,  carbonate,  sacch 

caseinate 

chlorid,  ferrous 

dialysed,  liq 

scales 

ferrocyanid 

glycerinophosphate , . . 

hydrocyanate 

hypophosphite 

iodid 

sacch 

lactate 

oxalate '. 

oxid,  black 

brown 

saccharated 

peptonized 

phosphate,  precip 

solution 

picrate  

pyrophosphate 

reduced 

salicylate 

subsulphate 

succinate 

sulphate 

dried 

tartrate 

valerianate 

and  ammon.  citr 

sulphate,  ferric 

and  magnesium  sulphate 

and  manganate  lactate 

and  manganate  peptonized,  dry 

and  maganate  sulphate 

and  potassium  tartrate 

and  quin.  arsenate 

citr 

citrate,  with  strychnine .   . . .  . 

hypophosphate 

valer 

and  sod.  oxal 

and  strychnin  cit  ate 

Isopral 

Isson 

Jaborandi 

Jalap 

Juglandin 

Juice,  belladonna. 

celandine 

cineraria,  in  eye 

conium 

digitalis 

hyoscyamus 


Grains  or  minims 


10—30 
3—10 
2—4 

10—30 

2—5 
2—5 

V2— 1 

5—10 

V^3 
2—5 
1—5 
2—6 
2—4 

60—240 

10—30 
5—20 
5—10 
5—10 

V4-I 
5—10 
2—5 
3—10 
2—5 

10—60 
1—3 

V2— 2 
5—10 
3—15 
3—10 
5—15 
5—10 
2—5 
5—20 
1—2 
5—10 

V.6— Vs 

3—10 
4—10 
3—10 
2—10 
3—15 
2—5 

7—22 
30—60 

10—30 
10—30 

2—5 

3—10 
10—20 

2—3 
20—60 

3—10 
30—60 


Grams  or  Cc. 


0.6 

0.2 

0.13 

0.6 

0.03 

0.13 

0.13 

0.03 

0.3 

0.03 

0.13 

0.06 

0.13 

0.13 

4. 

0.6 

0.3 

0.3 

0.3 

0.015 

0.3 

0.13 

0.2 

0.13 

0.6 

0.06 

0.03 

0.3 

0.2 

0.2 

0.3 

0.3 

0.13 

0.3 

0.06 

0.3 

0.004 

0.2 

0.25 

0.2 

0.13 

0.2 

0.13 

0.5 
2. 

0.6 

0.6 

0.13 

0.2 

0.6 

0.13 

1.3 

0.2 

2. 


2. 

0.6 

0.25 

2. 

0.13 

0.3 

0.3 

0.06 

0.6 

0.2 

0.3 

0.3 

0.4 

0.25 

15. 

2. 

1.25 

0.6 

0.6 

0.06 

0.6 

0.3 

0.6 

0.3 

4. 

0.2 

0.13 

0.6 

1. 

0.6 

1. 

0.6 

0.3 

1.25 

0.13 

0.6 

0.008 

0.6 

0.6 

0.6 

0.6 

1. 

0.3 

1.5 

4. 

2. 

2. 

0.3 

0.6 

1.3 

0.2 

4. 

0.6 

4. 


DOSE   TABLE 


627 


Remedy 

Grains  or  minims 

Grams  or  C.c. 

Juice,  pawpaw,  dry 

5—10 
60—240 
60—120 
60—240 

2—8 

3—8 
60—120 

5—20 
10—20 

3—5 
20—30 
15—30 
15—60 

5—10 

8—15 

20—60 

1—5 
10—20 

8—15 

2—220 

3—30 
15—30 

5—8 

1—4 

1—4 

1—4 

3—8 

2—4 
20—60 

1—8 

375 

60—240 

120—240 

'A— 2 

60—240 

8—24 

V60— Vie 
5—20 

5 

1—5 

5—20 

5—15 

5—15 

3—10 

1—3 

2—5 

5—20 

1—5 

10—30 

10—30 

10—30 

5—30 

5—15 

30—60 

0.3 
4. 
4. 
4. 

0.12 
02 
4. 
0.3 
0.6 
0.2 
J. 3 
1. 
1. 
0.3 
0.5 

1.3 
0.06 
0.6 
0.5 
0.13 
0.2 
1. 
0.3 
0.06 
0.06 
0.06 
0.2 
0.13 
1.3 
0.06 
25. 
4. 
8. 

0.015 
4. 
0.5 
0.001 
0.3 
0.3 
0.06 
0.3 
0.3 
0.3 
0.2 
0.06 
0.13 
0.3 
0.06 
0.6 
0.6 
0.6 
0.3 
0.3 
2. 

—  0.6 

sambucus 

—15. 

scoparius 

—  8. 

taraxacum 

—15. 

Kairin 

—  0.5 

Kalagua 

—  0.5 

Kamala 

—  8. 

Kermes  mineral,  emetic 

—  1.3 

Kino 

—  1.3 

Kolanin 

—  0.3 

Kosin 

—  2. 

Koussein,  amorph 

—  2. 

Krameria 

—  4. 

—  0.6 

Kryofin 

—  1. 

Labarraque's  solution 

—  4. 

Lactucin 

—  0.3 

Lactopeptin 

—  1.3 

Lactophenin 

—  1. 

Lactucarium   

—  1.3 

—  2. 

Lantanin 

—  2. 

—  0.5 

Lead,  acetate 

—  0.25 

—  0.25 

nitrate 

—  0.25 

Lecithin 

—  0.5 

Leontodin 

—  0.25 

—  4. 

Leptandrin 

—  0.5 

Levurinose 

—15. 

—15. 

Lime  sulphurated 

—  0.13 

Lipanin 

—15. 

Lithium,  acetate 

—  1.5 

—  0.004 

benzoate 

—  1.3 

borocitrate 

—  0.3 

—  1.3 

carbonate 

-  1. 

citrate 

—  1. 

dithiosalicyl 

—  0.6 

formate 

—  0.2 

glycerinophosphate 

—  0.3 

—  1.3 

iodid 

—  0.3 

—  2. 

salicylate       '. 

—  2. 

sulphate  (daily) 

—  2. 

urate  (daily) 

—  2. 

valerian   

—  1. 

vanadate  (daily) 

—  4. 

628 


APPENDIX 


Remedy 


Lithium  and  potassium  tartrate 

and  sod.  benz 

and  sod.  salicyl 

Lobelin  sulphate 

Loretin-bismuth 

Lugol's  solution 

Lupulin 

Lycetol 

Lycopin 

Lysol 

Macrotin 

Magnesium,  benzoate 

biphosphate 

bisulphate 

borate 

borocitr 

bromid 

cacodylate 

carbonate 

chlorid 

citrate 

copaivate 

ergotinate 

glycerino-phosphate 

gynocardate 

hydrate,  moist 

hypophosphate 

hyposulphate 

iodid 

lactate 

lactophosphate 

malate 

oxid 

peptonized 

phosphite 

salicylate 

silicate 

sulphate 

sulphite 

sulphophenolate 

valerianate 

Malakin 

Malarin 

Mallein,  horse 

Manganese,  arsenate 

bromid 

carbonate 

chlorid 

citrate 

dioxid 

hypophosphite 

iodid 

lactate 

lactophosphate 

oxid 


Grains  or  minims 

Grams  or  C.c. 

Vu 

0.004 

10—30 

0.6 

—  2. 

10—30 

0.6 

—  2. 

Ve— 1 

0.01 

—  0.06 

5—10 

0.3 

—  0.6 

2—10 

0.13 

—  0.6 

10—20 

0.6 

—  1.3 

4—10 

0.25 

—  0.6 

1—4 

0.06 

—  0.25 

30—120 

2. 

—  8. 

Vj— 2 

0.03 

—  0.13 

5—20 

0.3 

—  1.3 

10—30 

0.6 

—  2. 

5—20 

0.3 

—  1.3 

5—20 

0.3 

—  1.3 

15—30 

1. 

—  2. 

10—20 

0.6 

—  1.3 

V2— 1 

0.03 

—  0.06 

30—120 

2. 

—  8. 

240—480 

15. 

—30. 

30—120 

2. 

—  8. 

10—20 

0.6 

—  1.3 

V3— 1 

0.04 

—  0.06 

3—10 

0.2 

0.6 

15—60 

1. 

—  4. 

60—120 

4. 

—  8. 

10—20 

0.6 

—  1.3 

10—30 

0.6 

—  2. 

2—10 

0.13 

—  0.6 

15—45 

1. 

—  3. 

3—15 

0.2 

—  1. 

30—120 

2. 

—  8. 

10—60 

0.6 

—  4. 

1—2 

0.06 

—  0.12 

5—20 

0.3 

—  1.3 

15—60 

1. 

—  4. 

60—240 

4. 

—15. 

240—480 

15. 

—30. 

10—60 

0.6 

—  4. 

15—30 

1. 

—  2. 

3—10 

0.2 

—  0.6 

10—20 

0.6 

—13. 

8—15 

0.5 

—  1. 

Vr- 1 

0.04 

—  0.06 

Vso- V* 

0.002 

—  0.12 

2—8 

0.13 

—  0.5 

10—40 

0.6 

—  2.5 

3—12 

0.2 

—  0.75 

1—3 

0.06 

—  0.2 

2—10 

0.13 

—  0.6 

10—20 

0.6 

—  1.3 

1—3 

0.06 

—  0.2 

1—5 

0.06 

—  0.3 

1—5 

0.06 

—  0.3 

2—10 

0.12 

—  0.6 

DOSE   TABLE 


629 


Remedy 


Manganese,  peptonized 

phosphate 

salicylate 

sulphate 

sulphite 

sulphophenol  te 

and  i  on  lactate 

Mangasol 

Manna 

Mannit 

Maretin 

Mass,  blue 

copaiba 

ferrous  carbon 

Matico 

Meconarcein 

MeduUaden 

Melonemetin 

Menispermin 

Menispermum 

Menthol 

Mercurol 

Mercury,  albumin.,  liq 

amido-prepionate 

asparaginate 

benzoate,  mercuric 

bichlorid 

biniodid 

bisulphate 

bromid,  mercuric 

bromid,  mercurous 

cacodylate 

carbolate  

chlorid,  mild 

(cathartic) 

cyanid 

gallate 

glycocolate 

iodid,  proto 

naphtolate 

nitrate,  mercuric 

mercurous 

oxid,  black 

phosphate  (mercuric  and  mercurous) . 

salicylate 

sozoiodolate 

subsulphate 

(alterative) . 

succinimid 

sulphid,  black 

red 

tannate 

thymol-acetate 

tribrom  phenol-acetate 

and  antimony  sulphid 

and  arsen,  iod 


Grains  or  minims 


10—30 
1—5 
3—10 
5—15 
5—20 
3—15 
1—5 

10—30 
240—180 

60—480 
3—8 
3—15 

10—30 
3—6 

30—60 

V«— Vt 

30—45 
1— IV* 
1—5 

10—30 
3—5 
1—5 
8—15 

Vii— Ve 

Vi.-V. 

Vm— V. 
Vsj— Vi. 
Vii— v« 
V. 

VU— V4 

1 

V. 

V«— Vi 
V»— 1 
5—15 

Vl6— V« 

1—3 

V. 

Vr-2 
Vr-1 
Ve«— V. 

V.X— v« 

»/4— 3 

V.-1 
V.-1 

1—3 

2—5 

V4— V» 

V»— V. 

3—15 
15—30 

1—2 

1—2 

5 

2—4 


Grams  or  C.c. 


0.6 
0.06 
0.2 
0.3 
0.3 
0.2 
0.06 
0.6 
15. 
4. 
0.2 
0.2 
0.6 
0.2 
2. 

0.01 
2. 

0.06 
0.06 
0.6 
0.2 
0.06 
0.5 
0.005 
0.005 
0.002 
0.002 
0.004 
0.02 
0.004 

0.03 

0.015 

0.02 

0.3 

0.004 

0.06 

0.01 

0.03 

0.03 

0.001 

0.002 

0.015 

0.01 

0.02 

0.06 

0.13 

0.015 

0.012 

0.2 

1. 

0.06 

0.06 

0.13 
O.COl 


-  2. 

-  0.3 

-  0.6 

-  1. 

-  1.3 

-  1. 

-  0.3 

-  2. 
-30. 
-30. 

-  0.5 

-  1. 

-  2. 

-  0.4 

-  4. 

-  0.03 

-  3. 

-  0.1 

-  0.3 

-  2. 

-  0.3 

-  0.3 

-  1. 

-  0.01 

-  0.01 

-  0.008 

-  0.015 

-  0.005 

-  0.015 
0.006 

-  0.03 

-  0.06 

-  1. 

-  0.008 

-  0.2 

-  0.13 

-  0.06 

-  0.008 

-  0.015 

-  0.2 

-  0.06 

-  0.06 

-  0.2 

-  0.3 

-  0.03 

-  0.025 

-  1. 

-  2. 

-  0.13 

-  0.13 

-  0.3 

-  0.25 

-  0.002 


630 


APPENDIX 


Remedy 


Mercury  and  potassium  hyposulphate. 

with  chalk 

Mesotan 

Metacresol 

Metaldehyd 

Methacetin 

Methyl,  salicylate 

Methylal 

Methylen  blue 

Mezereum 

Migrainin 

Migrol 

Mirmol 

Mixture,  acid  sulphuric 

ammon.  chlor 

almond,  B.  P 

camphor,  acid 

chalk 

carminative 

chloral  and  potassium  bromide . . . 

chloroform 

and  cannab.  ind.  co 

copaiba  co 

creosote,  B.  P 

diarrhoea,  N.  F 

guaiac 

glycyrrhiza  co 

iron,  arom.,  B.P 

comp 

and  ammon.  acet 

licorice  comp 

magnes  and  asafet 

oil  tar 

oleobalsamic 

potass,  citr 

rhubarb  co 

rhubarb  and  soda 

sassafras  and  opium 

scammony,  B.  P 

soda  and  peppermint 

Monesin 

Monobromacetanilid 

Morphin 

Mucin 

Muscarin,  nitrate 

Musk 

Myricin 

Myrrh 

Myrtol 


Naphthalin 

Naphthol  (beta) 

Narcein , 

Narcotin 

Narcyl  (daily)  . 
Neurodin 


Grains  or  minims 


V5— Vs 

3—10 

60 

1—3 

2—8 

4—8 

5—10 

8—60 

2—4 

5—10 

15 

5—10 

480—600 

5—20 

60—240 

60—120 

60—240 

120—480 

60—240 

30—60 

60—240 

5—20 

60—240 

240—960 

15—60 

240—960 

120—240 

480—960 

480—960 

120—480 

120—360 

10—30 

30—120 

10—30 

120—480 

60—120 

240—960 

60—120 

480—960 

120—480 

V.o— V2 

2—8 
Vs— V2 
10 

V32— V16 
3—10 
1—3 
5—20 
5—15 

2—15 
3—8 
V3-I 
3—10 
1 
5—25 


Grams  or  C.c. 


0.012 

0.2 

4. 

0.06 

0.13 

0.25 

0.3 

0.5 

0.13 

0.3 

1. 

0.3 
30. 

0.3 

4. 

4. 

4. 

8. 

4. 

2. 

4. 

0.3 

4. 
15. 

1. 
15. 

8. 
30. 
30. 


0.6 

2. 

0.6 

8. 

4. 
15. 

4. 
30. 

8. 

0.006 

0.13 

0.008 

0.6 

0.002 

0.2 

0.06 

0.3 

0.3 

0.13 

0.2 

0.02 

0.2 

0.06 

0.3 


-  0.01 

-  0.06 

-  0.2 

-  0.5 

-  0.5 

-  0.6 

-  4. 

-  0.25 

-  0.06 

-  0.6 
-40. 

-  1.3 
-15. 

-  8. 
-15. 
-30. 
-15. 

-  4. 
-15. 

-  1.3 
-15. 
-60. 

-  4. 
-60. 
-15. 
-60. 
-60. 
-30. 
-24. 

-  2. 

-  8. 

-  2. 
30. 


—60. 


-60. 
-30. 

-  0.03 

-  0.5 

-  0.03 

-  0.004 

-  0.6 

-  0.2 

-  1.3 

-  1. 

-  1. 

-  0.5 

-  0.06 

-  0.6 

-  1.6 


DOSE   TABLE 


631 


Remedy 


Grains  or  minims 


Neuronal 

Nickel  bromid 

Nickel  sulphate 

Nicotin 

Nitroglucose 

Nuclein  (5  per  cent) 

Nutmeg 

Nutrose 

Nux  vomica 


Oculin 

Oil,  amber,  recti! 

almond,  expressed. 

animal 


anise 

balm 

basil 

birch  bark 

bitter  almond .... 

cajuput 

camphor 

Canada  snakeroot. 
canella 


caraway 

cardamon 

castor 

celery 

chamomile,  German. 

chaulmoogra 

chenopodium 

cherry-laurel 

cinnamon 

cloves 

cod-liver 

cochlearia 

cocoanut 

copaiba 

coriander 

croton 

cubebs 

cumin 

dill 


engeron 

eucalyptus 

fennel 

fir,  Scotch 

fireweed 

garlic 

gaultheria 

ginger 

hedeoma 

hops 

horsemint 

hyoscy  amus 

hyssop 

jatrppha  curcas. 


8—15 
5—10 

V2-I 

V64— V20 

Vso — V20 
10—60 

5—20 
15—30 

1—5 


Grams  or  C.c. 


0.5 

0.3 

0.03 

0.001 

0.0008 

0.6 

0.3 

1. 

0.06 


1. 

0.6 

0.06 

0.003 

0.003 

4. 

1.3 

2. 

0.3 


45 

3. 

5—15 

0.3 

—  1. 

120—480 

8. 

—30. 

5—20 

0.3 

1.3 

5—10 

0.3 

—  0.6 

1—2 

0.06 

—  0.13 

1—2 

0.06 

—  0.13 

5—30 

0.3 

—  2. 

Ve— V2 

0.01 

—  0.03 

5—20 

0.3 

—  1.3 

2—4 

0.13 

—  0.25 

1—2 

0.06 

—  0.13 

1—2 

0.06 

—  0.13 

1—10 

0.06 

—  0.6 

1—2 

0.06 

—  0.13 

240—480 

15. 

—30. 

1—2 

0.06 

—  0.13 

1—5 

0.06 

—  0.3 

4—20 

0.25 

—  1.3 

10 

0.6 

•A— V2 

0.01 

—  0.03 

1—3 

0.06 

—  0.2 

1—5 

0.06 

—  0.3 

60—240 

4. 

—15. 

2—5 

0.13 

—  0.3 

120—240 

8. 

—15. 

5—15 

0.3 

—  1. 

2—5 

0.13 

—  0.3 

1—2 

0.06 

—  0.13 

5—15 

0.3 

—  1. 

1—3 

0.06 

—  0.2 

3—10 

0.2 

—  0.6 

10—30 

0.6 

—  2. 

5—15 

0.3 

—  1. 

5—15 

0.3 

—  1. 

5—10 

0.3 

—  0.6 

2—6 

0.13 

—  0.4 

2—6 

0.13 

—  0.4 

5—20 

0.3 

—  1  3 

1—3 

0.06 

—  0.2 

3—10 

0.2 

—  0.6 

1—5 

0.06 

—  0.3 

2—10 

0.13 

—  0.6 

1—5 

0.06 

—  0.3 

1—5 

0.06 

—  0.3 

2—8 

0.13 

—  0.5 

632 


APPENDIX 


Remedy 


Oil,  juniper 

iaurel 

lavender 

male  fern 

marjoram,  wild. . 

matico 

mustard 

myrtle 

niaouli 

nutmeg 

expressed 

olive 

pennyroyal 

pepper 

peppermint 

phosphorated 

pimento 

pinus  pumilio 

rosemary 

rue 

santal 

sassafras 

savin 

sesam 

spearmint 

tansy 

tar 

thyme 

turpentine 

valerian 

wintergreen 

wormseed,  levant 

wormwood 

yarrow 

Oleocreosote 

Oleoguaiacol 

Oleoresin,  aspidium. . . 

capsicum 

cubebs 

ginger 

lupulin 

male  fern 

matico 

mezereon 

pepper 

Olibanum 

Opium,  powdered . . . . 
Orexin 

tannate 

Orphol 

Orthin  hydroch 

Orthoform 

New 

Ossagen  

Ovaraden 

Ovariin 


Grains  or  minims 

Grams  or  C.c. 

5—15 

0.3 

—  1. 

V2— 3 

0.03 

—  0.2 

1—5 

0.06 

—  0.3 

10—30 

0.6 

—  2. 

2—10 

0.13 

—  0.6 

V2— 1 

0.03 

—  0.06 

Vs— V4 

0.008 

—  0.015 

V2— 4 

0.03 

—  0.25 

4—15 

0.25 

—  1. 

1—5 

0.06 

—  0.3 

2—5 

0.13 

—  0.3 

120—480 

8. 

—30. 

3—10 

0.2 

—  0.6 

1—3 

0.06 

—  0.2 

1—5 

0.06 

—  0.3 

1—5 

0.06 

—  0.3 

2—5 

0.13 

—  0.3 

5—10 

0.3 

—  0.6 

2—5 

0.13 

—  0.3 

10—20 

0.6 

—  1.3 

5—20 

0.3 

—  1.3 

1—3 

0.06 

—  0.2 

1—5 

0.06 

—  0.3 

240—480 

15. 

—30. 

2—5 

0.13 

—  0.3 

1—5 

0.06 

—  0.3 

2—5 

0.13 

—  0.3 

3—10 

0.2 

—  0.6 

5—30 

0.3 

—  2. 

3—5 

0.2 

—  0.3 

5—20 

0.3 

—  1.3 

1—2 

0.06 

—  0.13 

1—2 

0.06 

—  0.13 

1—5 

0.06 

—  0.3 

10—40 

0.6 

—  2.5 

5—20 

0.3 

—  1.3 

120—240 

8. 

—15. 

V4— 1 

0.015 

—  0.06 

10—30 

0.6 

—  2. 

V2— 2 

0.03 

—  0.13 

2—5 

0.13 

—  0.3 

120—240 

8. 

—15. 

3—15 

0.2 

—  1. 

V2— 1 

0.03 

—  0.06 

V4— 1 

0.015 

—  0.06 

10—30 

0.6 

—  2. 

V2— 2 

0.03 

—  0.13 

4—10 

0.25 

—  0.6 

4—8 

0.25 

—  0.5 

5—15 

0.3 

—  1. 

3—7 

0.2 

—  0.45 

5—15 

0.3 

—  1. 

8—15 

0.5 

—  1. 

30—60 

2. 

—  4. 

15—30 

1. 

—  2. 

3—6 

0.2 

—  0.4 

DOSE   TABLE 


633 


Remedy 


Oxaphor  (daily) . .  . 

(oxycamphor) . 

Oxyspartein 


Palladium,  chlorid .  . .  . 

Pancreaden 

Pancreatin-albumin . . 

Pancreatin 

Pankreon 

Papain 

Papaverin,  child 

Paracotoin , 

Parachlorsalol 

Paracresalol 

Paraformaldehyd 

Paraldehyd 

Pareira 

Parthenicin 

Pelletierin  sulphate . . . 
Pelletierin  tannate. .  . . 
Pellotin  hydrochlor . . . 

Pental 

Pepper 

Pepsin 

sacchar 

Pereirin 

Peronin 

Petrolatum,  liq 

Phaselin 

Pheduretin 

Phenobromate 

Phenacetin 

Phenalgin 

Phenobromate 

PhenocoU  hydrochlor 

salicylate 

Phenolphthalein 

Phenosal 

Phenoxycaffein 

Phesin 

Phloridzin 

Phosphorus 

Phosote 

Phosphotal 

Phthisin 

Physostigmine  eserine. 

Phytin 

Phytolacca  root 

Phytolaccin 

Picrotoxin 

Piliganine 

Pilocarpin  hydrochlor . 

Pilocarpus 

.Pimenta 

Piperazin 

Plperidin,  tartrate   .  .  . 


Grains  or  minims 


45—60 
8—15 

V2— IV2 

Ve— V3 

15—60 

1—1 V2 

5—15 

2—8 

2—5 

V12— V3 

4—8 

5—15 

5—15 

8—15 

30—90 

30—60 

1—3 

5—10 

8—24 

V4— IV2 

180—300 

3—15 

5—15 

40—120 

10—30 

Vs-l 

60—180 
5—15 
8—15 
5—20 
8—24 
5—20 
5—10 
5—15 

10—20 
1—3 

10—20 
4—8 
8—30 

10—15 
Vioo — V20 

15—30 
1—15 
4—8 
V120 — '/so 
8 

1—5 
1—3 

Vioo — Vao 
Ve— Va 
Vs— 'A 
10—30 
10—40 
5—10 
5—15 


Grams  or  C.c. 


3. 

0.5 

0.03 

0.01 
1. 

0.06 
0.3 
0.12 
0.13 
0.005 
0.25 
0.3 
0.3 
0.5 
2. 
2. 

0.06 
0.3 
0.5 
0.05 
12. 
0.2 
0.3 
2.5 
0.6 
0.02 
4. 
0.3 
0.5 
0.3 
0.5 
0.3 
0.3 
0.3 
0.6 
0.06 
0.6 
0.25 
0.5 
0.6 

0.0006 
1. 

0.06 
0.25 
0.0005 
0.5 
0.06 
0.06 
0.0006 
0.01 
0.008 
0.6 
0.6 
0.3 
0.3 


-  4. 

-  1. 

-  0.1 

-  0.02 

-  4. 

-  0.1 

-  1. 

-  0.5 

-  0.3 

-  0.02 

-  .5 

-  1. 

-  1. 

-  1. 

-  6. 

-  4. 

-  0.2 

-  0.6 

-  1.5 

-  0.1 
-20. 

-  1. 

-  1. 

-  8. 

-  2. 

-  0.06 
-12. 

-  1. 

-  1. 

-  1.3 

-  1.5 

-  1.3 

-  0.5 

-  1. 

-  1.3 

-  0.2 

-  1.3 

-  0.5 

-  2. 
1. 

-  0.003 
2. 

1. 

-  0.5 

-  0.002 

-  0.3 
0.2 
0.002 
0.02 
0.015 
2. 
2.5 
0.6 

1. 


634 


APPENDIX 


Remedy 


Grains  or  minims 


Piperin 

Pipitzahoac 

Podophyllin 

(acute  constip.) 

Podophyllotoxin 

Poliganin 

Pomegranate 

Populin 

Potassa 

sulphurated , 

Potassium,  acetate 

antimonate 

arsenate 

arsenite 

benzoate 

bicarbonate 

bichromate 

binoxalate 

bisulphate 

bitartrate 

bromid 

camphorate 

cantharidate 

carbolate 

carbonate 

chlorate  

chlorid 

citrate 

chromate 

cy anid 

f  errocy  anid 

glycerinophosphate,  75  per  cent 

hydrate 

hypophosphite 

iodid 

nitrate 

nitrite 

osmate 

permanganate 

perchlorate 

phosphate 

salicylate 

salicylite 

succinate 

sulphate 

sulphite 

sulphocyan 

tartrate 

(laxative) 

tellurate 

valerianate 

and  sod.  tartrate 

Powder,  antimonial 

glycyrrhiz.  co 

jalap  CO 

"James" 


V2-I 
45—75 

Vs— V2 

V12— Ve 
Ve— V3 
60—120 

2—4 
V4-I 

2—10 
10—60 

8—24 
V20— Vio 
V32— V16 

5—20 
20—60 
V16— V4 
Vs- IV2 
60—120 
60—480 
15—60 
10—30 
Veoo — ^/soo 

1—5 
10—30 
10—20 

5—20 
10—40 
Ve— V2 
V16— Vs 
10—15 

4—10 
'A— 1 
10—30 

3—30 
10—60 
V4-2 

V16— v* 

1—2 

5—15 

10—30 

5—20 

5—15 

5—10 

20—120 

15—160 

1—3 

15—30 

60—150 

V4— V4 

2—5 

120—480 

2—10 

60—120 

20—60 

2—10 


Grams  or  C.c. 


0.03 

3. 

0.008 

0.05 

0.005 

0.01 

4. 

0.13 

0.015 

0.13 

0.6 

0.5 

0.003 

0.002 

0.3 

1.3 

0.004 

0.008 

4. 

4. 

1. 

0.6 

0.0001 

0.06 

0.5 

0.6 

0.3 

0.6 

0.01 

0.004 

0.6 

0.25 

0.015 

0.6 

0.2 

0.6 

0.015 

0.004 

0.06 

0.3 

0.6 

0.3 

0.3 

0.3 

1.3 

1. 

0.06 

1. 

4. 

0.015 

0.13 

8. 

0.13 

4. 

1.3 

0.13 


-  0.06 

-  5. 

-  0.03 

-  0.1 

-  0.01 

-  0.02 

-  8. 

-  0.25 

-  0.06 

-  0.6 

-  4. 

-  1.5 

-  0.006 

-  0.004 

-  1.3 

-  4. 

-  0.015 

-  0.1 
-8. 
-30. 

-  4. 

-  2. 

-  0.0002 

-  0.3 

-  2. 

-  1.3 

-  1.3 

-  2.5 

-  0.03 

-  0.008 

-  1. 

-  0.6 

-  0.06 

-  2. 

-  2. 

-  4. 

-  0.13 

-  0.015 

-  0.13 

-  1. 

-  2. 

-  1.3 

-  1. 

-  0.6 

-  8. 

-  4. 

-  0.2 

-  2. 
-10. 

-  0.05 

-  .03 
-15. 

-  0.6 

-  8. 

-  4. 

-  0.6 


DOSE   TABLE 


635 


Remedy 


Grains  or  minims 


Powder,  morph.  co 

rhubarb  co 

Prasoid 

Prostaden 

Protan 

Protonuclein 

Protylin 

Ptelein 

Ptyalin 

pepsin 

Pumpkin  seed 

Pyoktanin 

Pyramidon 

Pyramidon,  camphorate,  neutral. 

salicylate 

Pyrantin 

Pyranum 

Pyridin 

Pyrodin 

Pyrosal 


Quassia 

Quassin,  pure 

French 

Quebrachin 

Quillaja 

Quinacetin  sulph 

Quinalgen 

Quinaphtol 

Quinetum 

Quinidin 

Quinin  and  salts 

albuminate 

antimonate 

arsenate 

arsenite 

biniodid  (subcut.) 

dihydrobromate 

ferroarsenate 

f  erroarsenite 

f  errocy  anid 

f  erroiodid 

ferrolactate 

glycerinophos 

peptonate 

salicylate 

sulphocarbol 

tannate,  child 

valerian 

and  antipyrin  salicylate 

and  urea  hydrochlor.,  subcut. 

Quinoidin 

Quinolin,  salicylate 

and  antipyrin  valerianate. . .  . 

sulph 

tartrate 


5—20 
30—120 
15—30 

5—15 
20—30 

3—10 
15—60 

1—3 
10—30 
10—30 
60—120 

1—5 

3—8 
12—15 

8—12 

5—15 
15—30 

2—10 

V4-1 

8—15 

10—30 

Vso— Vs 
V2— 2 
1—2 
10—30 
5—15 
5—15 
8—15 
1—8 
V2— 3 
2—15 
2—15 
IV2— 6 
V16— '/s 

V.6— Vs 

3—20 

V.5— V» 

5—10 

8—15 

8—15 

2—5 

5—60 

2—30 

2—8 

5—15 

2—6 

2—8 

2—8 

2—15 

8—15 

2—8 

5—20 

5—20 


Grams  or  C.c. 


0.3 

2. 

1. 

0.3 

1.3 

0.2 

1. 

0.06 

0.6 

0.6 

4. 

0.06 

0.2 

0.75 

0.5 

0.3 

1. 

0.13 

0.015 

0.5 

0.6 

0.002 

0.03 

0.06 

0.6 

0.3 

0.3 

0.5 

0.06 

0.03 

0.13 

0.13 

0.1 

0.004 

0.004 

0.1 

0.2 

0.004 

0.004 

0.3 

0.5 

0.5 

0.13 

0.3 

0.13 

0.13 

0.3 

0.13 

0.12 

0.13 

0.13 

0.5 

0.12 

0.3 

0.3 


—  1.3 

—  8. 

—  2. 

—  1. 

—  2. 

—  0.6 

—  4. 

—  0.2 

—  2. 

—  2. 

—  8. 

—  0.3 

—  0.5 

—  1. 

—  0.75 

—  1. 

—  2. 

—  0.6 

—  0.06 

—  1. 

—  2. 

—  0.02 

—  0.13 

—  0.13 

—  2. 

—  1.       . 

—  1. 

—  1. 

—  0.5 

—  0.2 

—  1. 

—  1. 

—  0.4 

—  0.008 

—  0.008 

—  0.3 

—  0.008 

—  0.008 

—  0.6 

—  1. 

—  1. 

—  0.3 

—  4. 

—  2. 

—  0.5 

—  1. 

—  0.4 

—  0.5 

—  0.5 

—  1. 

—  1. 

—  0.5 

—  1.3 

—  1.3 


636 


APPENDIX 


Remedy 


Quinoral 

Quinopyrin 

Renaden 

Resin,  copaiba 

jalap 

podophyllum 

quebracho 

scammony 

sumbul 

veratrum 

Resopyrin 

Resorcin 

Rhamnin 

Rhubarb 

Rhusin 

Rubidium  bromid 

iodid 

and  ammon  bromid . 
Rumin 


Saccharin 

Saffron 

Safrol 

Salacetol 

Salfene 

Salibromin 

Salicin 

Salicylamid 

Salicyl-resorcin 

Saliformin 

Saligenin 

Salipyrin 

SalocoU 

Salol 

Salophen 

Saloquinin 

Salicylate 

Sanguinaria 

Sanguinarin 

Sanguinoform 

Santonin 

Santoninoxim 

Sarcosin 

Scammony 

Scillipicrin 

Scillitin 

Scillitoxin 

Scoparin 

Scopolamin  hy drobrom . . 

Scutellarin 

Senecin 

Senegin 

Senna 

Serpentaria 

Serum,  antistreptococcic. 


Grains  or  minima 

Grams  or  C.c. 

8     20 

0.5 

—  1.3 

8—25 

0.5 

—  1.5 

30 

2. 

5—15 

0.3 

—  1. 

1—3 

0.06 

—  0.2 

V8— Vi 

0.008 

—  0.03 

1—2 

0.06 

—  0.12 

3—8 

0.2 

—  0.5 

1—8 

0.06 

—  0.5 

Ve- V4 

0.01 

—  0.015 

5—10 

0.3 

—  0.6 

2—3 

0.13 

—  0.2 

2—6 

0.13 

—  0.4 

3—10 

0.2 

—  0.6 

1—2 

0.06 

—  0.13 

5—15 

0.3 

—  1. 

1—5 

0.06 

—  0.3 

20—60 

1.3 

—  4. 

1—3 

0.06 

—  0.2 

1—5 

0.06 

—  0.3 

10—20 

0.6 

—  1.3 

30—60 

2. 

—  4. 

15—45 

1. 

—  3. 

5—10 

0.3 

—  0.6 

30—75 

2. 

—  5. 

10—30 

0.6 

—  2. 

3—5 

0.2 

—  0.3 

5—15 

0.3 

—  1. 

5—10 

0.3 

—  0.6 

5—15 

0.3 

—  1. 

10—30 

0.6 

—  2. 

10—20 

0.6 

—  1.3 

5—15 

0.3 

—  1. 

10—20 

0.6 

—  1.3 

8—30 

0.5 

—  2. 

10—15 

0.6 

—  1. 

3—20 

0.2 

—  1.3 

Vl2— V3 

0.005 

—  0.2 

30 

2. 

2—4 

0.13 

—  0.25 

1—5 

0.06 

—  0.3 

8—15 

0.5 

—  1. 

5—15 

0.3 

—  1. 

Vs- 1 

0.02 

—  0.06 

Ve— V2 

0.01 

—  0.03 

Veo- V30 

0.001 

—  0.002 

5—15 

0.3 

—  1. 

7^50- Veo 

0.00025—0.001 

1—4 

0.06 

—  0.25 

1—3 

0.06 

—  0.2 

Vi— 2 

0.03 

—  0.13 

60—240 

4. 

—15. 

10—30 

0.6 

—  0.2 

150—300 

10. 

—20. 

DOSE   TABLE 


637 


Remedy 


Sidonal 

new 

Silin  (daily) 

Silver,  arsenite 

chlorid 

cyanid 

iodate 

iodid 

nitrate 

oxid 

Smilacin  amorph 

Soap 

Soda  (caustic) 

Sodium,  acetate 

anisate 

arsenate 

benzoate 

bicarbonate 

bisulphite 

borate 

borobenzoate 

borocitr 

borosalicyl 

borotartrate 

bromid 

cacodylate 

carbolate 

carbonate 

cetrarate 

chlorate 

chlorid 

chloroborate 

choleate 

cinnimate,  subcut 

citrate 

citrobenzoate 

copaivate 

cresotinate 

cyanid 

dithiosalicylate 

ethyl-sulph 

fluorbenzonate 

fluorid 

formate 

glycerino-phosph  (75  per  cent) 

glycocholate  (daily) 

gynocardate 

hippurate 

hydrate 

hypophosphite 

hyposulph 

iodid 

lactate 

meta-vanadate 

methylarsenate  (daily) 

naphtolate 


Grains  or  minims 


15- 
30- 
45 

Vl20- 
V2- 

Veo- 

Vi2- 

Vs- 

'/.2- 
1- 

3- 

'k- 

15- 

5- 

V24- 

10- 

10- 

10- 

20- 

30- 

15- 

5- 

1- 

10- 

1- 

2- 

5- 

3- 

5- 

10- 

10- 

5- 

Vs- 

15- 

5- 

10- 

3- 

V20- 

2- 

60- 

5- 

V.2- 

Vr- 

4- 

60- 

5- 

10- 

V2- 

10- 

5- 

5- 

120- 

Veo- 

v«- 

3- 


-20 
-45 

-Veo 

-IV2 

-V20 

-Vs 

-1 

-V2 

-'A 

-3 

-10 

-1 

-120 

-15 

-Vs 

-40 

-40 

-30 

-40 

-120 

-30 

-15 

-2 

-60 

-5 

-10 

-20 

-15 

-15 

-60 

-15 

-10 

-1 

-60 

-15 

-30 

-24 

-•A 

-10 

-300 

-10 

-Ve 

-3 

-10 

-75 

-15 

-20 

-1 

-30 

-20 

-60 

-480 

-v« 
-1V2 

-10 


Grams  or  C.c. 


1. 
2. 
3. 

0.0005 
0.03 
0.001 
0.005 
0.015 
0.008 
0.005 
0.06 
0.2 
0.03 
1. 
0.3 

0.0025 
0.6 
0.6 
0.6 
1.3 
2. 
1. 
0.3 
15. 
0.6 
0.06 
0.13 
0.3 
0.2 
0.3 
0.6 
0.6 
0.3 
0.02 
1. 
0.3 
0.6 
0.2 
0.003 
0.13 
4. 
0.3 
0.005 
0.03 
0.25 
4. 
0.3 
0.6 
0.03 
0.6 
0.3 
0.3 
8. 

0.001 
0.03 
0.2 


-  1.3 

-  3. 

-  0.001 

-  0.01 

-  0.003 

-  0.0 

-  0.06 

-  0.03 

-  0.03 

-  0.2 

-  0.6 

-  0.06 

-  8. 

-  1. 

-  0.008 

-  2.5 

-  2.5 

-  2. 

-  2.5 

-  8. 

-  2. 

-  1. 
-30. 

-  4. 

-  0.3 

-  0.6 

-  1.3 

-  1. 

-  1. 

-  4. 

-  1. 

-  0.6 

-  0.06 

-  4. 

-  1. 

-  2. 

-  1.5 

-  0.015 

-  0.6 
-20. 

-  0.6 

-  0.01 

-  0.2 

-  0.6 

-  5. 

-  1. 

-  3.1 

-  0.06 

-  2. 

-  1.3 

-  4. 
-15. 

-  0.008 

-  0.1 

-  0.6 


638 


APPENDIX 


Remedy 


Sodium,  nitrate 

nitrite 

oleate 

paracresotate 

persulphate 

phenolsulphonate 

phosphate 

pyrophosph 

saccharinate 

salicylate 

santonate 

santoninate 

sozoidole 

succinate 

sulphanilate 

sulphate 

sulphite 

sulphosalicyl 

sulphovinate 

tartrate 

taurochol 

tellurate 

thiosulph 

valerianate 

vanadate 

Solanin 

Solution,  acid  arsenous 

acid  phosphoric  comp . . . 

alumin,  acet . . . 

ammon,  acet 

concent 

citrate,  cone 

ammon.  succin 

arsen.  and  mere,  iod 

atropin  sulphate 

bismuth 

bismuth  and  ammon.  ctr 

cal.  chlorydrophos 

chlorid 

ergotin 

ext.  licorice 

Fowler's 

ginger 

gold  and  arsen.  bromides 

hydrogen  perox 

hypophosphites 

iodin  comp 

iron  acetate 

cone 

iron  album 

iron  chlor.  ferrous 

iron  citr 

iron  iodid . . 

iron  malate 

iron  nitr 

iron  oxy chlor 


Grains  or  minims 


10—60 

1—3 

2—5 

2—20 

1—3 

8—30 

5—40 

5—40 

1—5 

5—40 

1—6 

1—6 

5—30 

1—5 

10—15 

120—480 

10—60 

10—30 

60—300 

240—480 

2—6 

•A— 1 

5—20 

1—5 

V64— VS 
V4-1 

2 g 

60—120 

5—15 

120—480 

30—120 

30—60 

20—30 

5—10 

1—4 
60—240 
30—120 

5—10 
15—60 
10—30 
60—120 

1—5 
30—120 

5—15 
60—240 
15—60 

2—10 

2—10 

1—5 
60—240 

5—15 

5—15 

1—5 
30—120 

5—15 
10—30 


Grams  or  C.c. 


0.6 

0.06 
0,12 
0.13 
0.06 
0.5 
0.3 
0.3 
0.06 
0.3 
0.06 
0.06 
0.3 
0.06 
0.6 
8. 
0.6 
0.6 
4. 
15. 
0.13 
0.015 
0.3 
0.06 
0.001 
0.015 
0.13 
4. 
0.3 
8. 
2. 
2. 
13 
0.3 
0.06 
0.4 
2. 
0.3 
1. 
0.6 
4. 

0.06 
2. 
0.3 
4. 
1. 

0.13 
0.13 
0.06 
4. 
0.3 
0.3 
0.06 
2. 
0.3 
0.6 


-  4. 

-  0.2 

-  0.3 

-  1.3 

-  0.2 

-  2. 

-  2.5 

-  2.5 

-  0.3 

-  2.5 

-  0.4 

-  0.4 

-  2. 

-  0.3 

-  1. 
-30. 

-  4. 

-  2. 
20. 

-30. 

-  0.4 

-  0.06 

-  1.3 

-  0.3 

-  0.008 

-  0.06 

-  0.5 

-  8. 

-  1. 
-30. 

-  8. 

-  4. 

-  2. 

-  0.6 

-  0.25 

-  15. 

-  8. 

-  0.6 

-  4. 

-  2. 

-  8. 

-  0.3 

-  8. 

-  1. 
15. 

-  4. 

-  0.6 

-  0.6 

-  0.3 
-15. 

-  1. 

-  1. 

-  0.3 

-  8. 

-  1. 

-  2. 


DOSE   TABLE 


639 


Remedy 


Solution,  iron  protochlor 

iron  subsulph 

iron  and  ammon.  acet. .  . . 

iron  and  ammon.  citr 

iron  and  mangan.  pept . .  . 

lime,  chlorin 

sacchar 

magnes.  carbon 

magnesium  bromid 

glycochol 

mercury  and  potass,  iodid 

morphin  acet 

citrate 

sulph 

nitroglycer 

pancreatic 

pepsin 

arom 

phosphorus 

potassa 

potass,  arsenate  and  brom 
arsenite 

saccharin 

soda,  chlorin 

sodium  arsenate 

hydrate 

Somnal 

Somnalgesin 

Somnoform 

Spartein  sulph 

Spasmotin 

Sphacelotoxin 

Spigelia 

Spinol 

Spirit,  ammonia,  arom 

anise 

aromatic 

chloroform 

cinnamon 

ether 

comp 

gaultheria 

glonoin 

juniper 

comp 

melissa.  cone 

nitroglycer.  (spt.  glonoin). 

nitrous  ether 

nutmeg 

phosphorus 

spearmint 

witch-hazel 

Squill 

Starch, iodized  

Steresol 

Stillingin 


Grains  or  minims 


1- 

2- 

240- 

5- 

30- 

20- 

15- 

480- 

60- 

8- 

2- 

15- 

4- 

15- 

1- 

60- 

30- 

60- 

20- 

5- 

1- 

1- 

5- 

20- 

3- 

5- 

15- 

1- 

5- 

V4- 
V2- 

60- 

1- 

60- 

30- 

30- 

30- 

10- 

30- 

30- 

30- 

1- 

60- 

240- 

30- 

1- 

30- 

30- 

10- 

15- 

3- 

1- 

3- 

K- 
2- 


-5 

-10 

-480 

-20 

-60 

-60 

-60 

-960 

-120 

-15 

-5 

-60 

-15 

-60 

-3 

-240 

-120 

-240 

-60 

-20 

-5 

-5 

-30 

-60 

-10 

-20 

-30 

-5 

-7 

-1 

-IV2 

'Vh 

-120 

-8 

-120 

-120 

-120 

-60 

-30 

-60 

-60 

-120 

-3 

-180 

-480 

-60 

-3 

-90 

-120 

-40 

-40 

-15 

-3 

-10 

-1 

-4 


Grams  or  C.c. 


0.06 

0.13 
15. 

0.3 

2. 

1.3 

1. 
30. 

4. 

0.5 

0.13 

1. 

0.25 

1. 

0.06 

4. 

2. 

4. 

1.3 

0.3 

0.06 

0.06 

0.3 

1.3 

0.2 

0.3 

1. 

0.06 

0.3 

0.015 

0.03 

0.03 

4. 

0.06 

4. 

2. 

2. 

2. 

0.6 

2. 

2. 

2. 

0.06 

4. 
15. 

2. 

0.06 

2. 

2. 

0.6 

1. 

0.2 

0.06 

0.2 

0.015 

0.13 


-  0.3 

-  0.06 
-30. 

-  1.3 

-  4. 

-  4. 

-  4. 
-60. 

-  8. 

-  1. 

-  0.3 

-  4. 

-  1. 

-  4. 

-  0.2 
-15. 

-  8. 
15. 

-  4. 

-  1.3 

-  0.3 

-  0.3 

-  2. 

-  4. 

-  0.6 

-  1.3 

-  2. 

-  0.3 

-  0.4 

-  0.06 

-  0.1 

-  0.1 

-  8. 
0.5 


-  4. 

-  2. 

-  4. 

-  4. 

-  8. 

-  0.2 
12. 

-30. 

-  4. 

-  2. 

-  6. 

-  8. 

-  2.5 
2.5 

-  1. 

-  0.2 

-  0.6 

-  0.06 

-  0.25 


640 


APPENDIX 


Remedy 


Storax 

Stramonium  seed 

leaves 

Strontium,  acetate 

arsenite. 

bromid. 

iodid 

lactate 

salicylate 

Strophanthin 

Strychnin 

arsenate 

arsenite 

cacodylate 

hypophosp 

nitrate 

sulphate 

Stypticin 

Styptol 

Sugar,  milk,  daily 

Sulf  onal 

Sulphaminol,  salicylate. .  . 
Sulphur,  iodid 

precipit 

washed 

Syrup,  acacia 

acid  citric 

acid  hydriod 

blackberry,  arom .... 

calcium,  iodid 

lactophosphate 

with  iron 

and  sod.  hypophosph. 

chondrus,  comp 

chloral  


cinnamon 

codein 

eriodictyon,  arom 

garlic 

ginger 

gly  cyrrhiza 

hypophosphites 

with  iron 

ipecac 

and  opium 

iron  arsen 

bromid 

citro-iodid 

hypophosph 

iodid 

lactophosphate 

oxid 

phosphate 

protochlor 

quin.  and  strych.  phosph. 
saccharated 


trains  or  minims 


5—20 

1—3 

2—5 

V4— 1 
VSO- Vl5 

10—40 
10—20 
10—30 
10—40 

u 


V200 — * 
^/eo — ' 
^/64 — ^ 

V64— » 

'/so — 

V32 ' 

V64-» 
V64— ' 

1— 2V2 

1—6  oz. 

15—45 

3—6 

1—4 

30—120 

60—180 

120—480 

120—480 
30—60 

120—240 
60—120 
60—120 
60—240 
60—240 
60—120 
30—120 
60—240 
60—240 
60—240 
60—120 

120—240 
60—240 
60—240 
60—120 
20—240 
60—180 
60—120 
10—30 
15—60 
60—180 
15—30 
60—120 
60—120 
30—60 
30—120 
60—120 
60—180 


Grams  or  C.c. 


0.3 
0.06 
0.13 
0.015 
0.002 
0.6 
0.6 
0.6 
0.6 

0.0003 
0.001 
0.001 
0.001 
0.002 
0.002 
0.001 
0.001 
0.025 
0.06 
30. 
1. 
0.2 
0.06 
2. 
4. 


2. 

8. 

4. 

4. 

4. 

4. 

4. 

2. 

4. 

4. 

4. 

4. 

8. 

4. 

4. 

4. 

1.3 

4. 

4. 

0.6 

1. 

4. 

1. 

4. 

4. 

2. 

2. 

4. 

4. 


-  1.3 

-  0.2 

-  0.3 

-  0.06 

-  0.004 

-  2.5 

-  1.3 

-  2. 

-  2.5 

-  0.001 

-  0.004 

-  0.004 

-  0.004 

-  0.02 

-  0.005 

-  0.002 

-  0.00 

-  0.05 

-  0.15 
-180. 

-  3. 

-  0.4 

-  0.25 

-  8. 

-  12. 

-  30. 

-  30. 

-  4. 

-  15. 


15. 
15. 


15. 
15. 
15. 

8. 
15. 
15. 
15. 

8. 
15. 
12. 

8. 

2. 

4. 
12. 

2. 


4. 

8. 

8. 

12. 


DOSE   TABLE 


641 


Remedy 


Syrup,  iron,  arsen.,  mangan.  iodid 

krameria 

lactucarium. 

lemon 

lime 

manna 

orange 

flowers 

pectoral 

peppermint 

phosphates,  comp 

poppy 

prun.  virg 

raspberry 

rhamnus  cath 

rhoeados 

rhubarb 

and  potassa,  comp 

roses 

rubus 

sanguinaria 

sarsaparilla,  co 

senega 

senna 

aromat 

comp 

sodium  hypophosph 

squill 

comp 

stillingia,  comp 

tar 

trifolium,  comp 

violets 

wild  cherry 

white  pine,  comp 

Taka  diastase 

Tannalbin 

Tannigen 

Tannin 

Tannoform 

Tannopin 

Tannosal 

Taphosote 

Tar 

Tartar  emetic 

(expectorant) 

(emetic) 

Terebene 

Terpene  hydrochlorid 

Terpin  hydrate 

Terpinol 

Tetronal 

Testaden 

Thallin,  periodid 

tartrate 


Grains  or  minims 


10—30 

60—240 

30—120 

30—60 

30—60 

60—240 

120—480 
60—180 
60—120 
60—180 
60—120 
60—120 
60—240 
60—240 
60—250 
30—60 
60—480 
60—240 
30—60 

120—240 
15—60 

120—480 
30—120 

120—240 
60—240 
60—240 
60—240 
30—60 
15—60 
60—240 
60—240 
60—240 
60—240 
60—240 
60—240 

1—5 

5—30 

5—30 

2—20 

4—15 

8—30 

15—60 

15—30 

30—60 

V32— Vie 

V«— '/3 

Vs 

4—20 
15—30 

3—15 

2—5 
15—30 
30 

2—3 

3—8 


Grams  or  C.c. 


0.6 

4. 

2. 

2. 

2. 

4. 

8. 

4. 

4. 

4. 

4. 

4. 

4. 

4. 

4. 

2. 

4. 

4. 

2. 


1.  — 

8.  — 

2.  — 

8. 
4. 
4. 
4. 
2. 
1. 
4. 
4. 
4. 
4. 
4. 
4. 

0.06 

0.3 

0.3 

0.13 

0.25 

0.5 

1. 

1. 

2. 

0.002 

0.0025 

0.03 

0.25 

1. 

0.2 

0.13 

1. 

2. 

0.12 

0.2 


-  2. 
-15. 

-  8. 

-  4. 

-  4. 
-15. 
-30. 
-12. 

-  8. 
-12. 


15. 
15. 
15. 

4. 
30. 
15. 

4. 
15. 

4. 
15. 

8. 
-15. 
-15. 
15. 
-15. 

-  4. 

-  4. 
-15. 
-15. 
-15. 
-15. 
-15. 

15. 

-  0.3 

-  2. 

-  2. 
-13. 

-  1. 

-  2. 

-  4. 

-  2. 

-  4. 

-  0.004 

-  0.008 

-  1.3 

-  2. 

-  1. 

-  0.3 

-  2. 

-  0.2 

-  0.5 


642 


APPENDIX 


Remedy 


Thallin,  sulphate 

tartrate 

Thallium  acetate 

Thallium,  chlorid 

sulphate 

Thanatol  =guethol 

Thebain,  hydrochlorid . . 
Theobromin 

and  lith,  benz 

and  lith.  salicylate . 

and  sod.  benz 

and  sod.  iodosalicyl 

and  sod.  salicyl 

Theocin 

Theocin-sodium  acetate 
Theophyllin 

sodium 

sodium  salicylate . . 

Thermifugin 

Thermodin 

Thermol 

Thiocol 

Thiosinamin 

Thymacetin 

Thymol 

Thyraden 

Thyroidin  (Merck) 

Tin  chlorid  stannous.  . . 

Tincture,  aconite 

Fleming 

adonis  aestiv 

vernalis 

adulsa  vasaca 

aloes 

and  myrrh 

antiperiodic 

apocynum 

arnica  flow 

root 

asafetida 

avena  sativa 

sat.,  CO 

belladonna  Ivs 

benzoin 

comp 

bryonia 

bursa  pastor 

cactus  grandiflor. . . 

cannab. ind 

cantharides 

capsicum 

cardamom 

castoreum , 

catechu  co 

cinchona 

^imicifuga 


Grains  or  minims 

Grams  or  C.c. 

3—8 

0.2 

—  0.5 

3—8 

0.2 

—  0.5 

I'A— 3 

0.1 

—  0.2 

Vs 

0.012 

Vs 

0.012 

5—10 

0.3 

—  0.6 

1—3 

0.06 

—  0.2 

5—15 

0.3 

—  1. 

5—15 

0.3 

—  1. 

5—15 

0.3 

—  1. 

15—1 

1. 

4—8 

0.25 

—  0.5 

15 

1. 

3—8 

0.2 

—  0.5 

5—8 

5.0 

—  0.3 

3—8 

0.2 

—  0.5 

7 

0.4 

8 

0.5 

4 

0.25 

5—20 

0.3 

—  1.3 

5—15 

0.3 

—  1. 

5—20 

0.3 

—  1.3 

V2— IV2 

0.03 

—  0.1 

5—15 

0.3 

—  1. 

1—10 

0.06 

—  0.6 

2—4 

0.13 

—  0.25 

72-2 

0.03 

—  0.13 

V.«— V2 

0.005 

—  0.03 

1—3 

0.06 

—  0.2 

V2— 2 

0.03 

—  0.13 

10—30 

0.6 

—  2. 

3—20 

0.2 

—  1.3 

30—60 

2. 

—  4. 

15—60 

1. 

—  4. 

30—120 

2. 

—  8. 

20—60 

1.3 

—  4. 

10—60 

0.6 

—  4. 

10—30 

0.6 

0 

20—40 

1.3 

—  5. 

20—60 

1.3 

—  4. 

10—60 

0.6 

—  4. 

10—15 

0.6 

—  1. 

5—20 

0.3 

—  1.3 

20—40 

1.3 

—  2.5 

30—60 

2. 

—  4. 

60—240 

4. 

—15. 

30 

2. 

10—15 

0.6 

—  1. 

5—20 

0.3 

—  1.3 

3—10 

0.2 

—  0.6 

15—60 

1. 

—  4. 

60—120 

4. 

—  8. 

30—120 

2. 

—  8. 

60—120 

4. 

—  8. 

60—120 

4. 

—  8. 

60—120 

4. 

—  8. 

DOSE   TABLE 


643 


Remedy 


Tincture,  cinnamon. , . . 

seed 

convallaria 

coronilla 

coto 

gelsemium 

gentian  co 

ginger 

guaiac 

ammon 

hops 

Hydrastis 

hyoscyamus 

iodin 

comp 

ipecac  and  opium. . 
iron,  acet.,  ether. . . 

chlor 

chlor.,  ether 

citro-chlor 

pomated 

jalap 

kino 

lactucarium 

lobelia 

musk 

myrrh 

naregamia 

nerium  oleander  Ivs 

nutgall 

nux  vom 

opium 

opium  camph 

paracoto 

physostigma 

Pulsatilla 

quassia 

quillaja 

rhubarb 

aqueous 

arom 

sweet 

and  gentian 

toxicodend 

saffron 

serpentaria 

simulo 

squill 

stramonium 

strophanthus 

sumbul 

tolu 

valerian,  ammon. . . 
veratrum,  br 

vir 

Warburg's 


Grains  or  minims 


60- 

20- 

5- 

5- 

10- 

10- 

60- 

15- 

20- 

60- 

60- 

30- 

20- 

3- 

5- 

5- 

10- 

5- 

10- 

10- 

30- 

5- 

60- 

6- 

10- 

30- 

30- 

20 

30- 

5- 

5- 

60- 

10- 

5- 

5- 

60- 

20- 

60- 

60- 

30- 

60- 

60- 

5- 

60- 

60- 

30- 

6- 

6- 

3- 

15- 

30- 

60- 

5- 

3- 

20- 


-240 

-60 

-20 

-15 

-20 

-30 

-120 

-60 

-60 

-120 

-180 

-120 

-60 

-10 

-15 

-15 

-30 

-20 

-30 

-30 

-90 

-20 

-180 

-40 

-40 

-120 

-120 

-2 

-60 

-20 

-20 

-240 

-20 

-15 

-20 

-180 

-60 

-240 

-240 

-120 

-240 

-240 

-30 

-180 

-180 

-60 

-20 

-20 

-10 

-60 

-120 

-120 

-20 

-10 

-60 


Grams  or  C.c. 


4. 

1.3 

0.3 

0.3 

0.6 

0.6 

4. 

1. 

1.3 

4. 

4. 

2. 

1.3 

0.2 

0.3 

0.3 

0.6 

0.3 

0.6 

0.6 

2. 

0.3 

4. 

0.4 

0.6 

2. 

2. 

0.03 

2. 

0.3 

0.3 

4. 

0.6 

0.3 

0.3 

4. 

1.3 

4. 

4. 

2. 

4. 

4. 

0.3 

4. 

4. 

2. 

0.4 

0.4 

0.2 

1. 

2. 

4. 

0.3 

0.2 

1.3 


—15. 

—  4. 

—  1.3 

—  1. 

—  1.3 

—  2. 

—  8. 
-^  4. 

—  4. 

—  8. 
—12. 

—  8. 

—  4. 

—  0.6 

—  1. 

—  1. 

—  2. 

—  1.3 

—  2. 

—  2. 

—  6. 

—  3. 
—12. 

—  2.5 

—  2.5 


—  0.13 
1.3 

—  4. 

—  1.3 

—  1.3 
—15. 

—  1.3 

—  1. 

—  1.3 
—12. 

—  4. 

—  15. 
—15. 

—  8. 
—15. 
—15. 

—  2. 
—12. 
—12. 

—  4. 

—  1.3 

—  1.3 

—  1.6 

—  4. 


1.3 
0.6 
4. 


644 


APPENDIX 


Remedy 


Tolypyrin 

Tolysal 

Tribrommethan  =bromoform 

Tribromphenol 

Tribromsalol 

Trif  errin 

Trigemin 

Trilliin 

Trional 

Trioxymethylen 

Triphenin 

Trypsin 

Tuberculin , 

Turpentine,  chian 

Tussol 

Ulexin 

Uraliam 

Uranium  nitrate 

Urea 

Urethan 

Uricedin 

Uriseptin 

Urosin 

Urotropin 

Uva  ursi 

Valerian 

Valerydin 

Validol 

camphorated 

Valofin 

Valyl 

Vanadin,  daily 

Vanillin 

Veratrin  alkaloid 

Veratrol 

Veronal 

Viburnin 

Vieirin 

Vinegar  opium 

Vinegar  squill 

Water,  ammonia 

cone 

bitter  almond 

cherry  laurel 

chlorin 

Wine,  aloes 

camphorated 

colchicum  seed 

ipecac 

emetic 

iron 

bitter 

opium 


Grains  or  minims 


5—15 
8—30 
2—20 
3—10 

15—30 
5 

5—20 
2—4 

15—30 
8—15 
4—20 
8—24 

'Aon — Vi20 

2—5 
2—15 

Vio— Viu 
30—45 

1—15 
10—20 
10— 4a 
15—30 
60—120 
10—15 

8—15 
60—120 

10—30 

8—15 

10—20 

10—15 

10—25 

2—6 

6—30 

Veo- V20 
1—2 
5—15 
1—3 
1—4 
5—20 

10—30 

10—30 

4—10 

10—20 

10—20 

15—240 

60—120 

60—240 

20—60 

5—10 

60—180 

60—240 

120—180 

5—20 


Grams  or  C.c. 


0.3 

0.5 

0.13 

0.2 

1. 

0.3 

0.3 

0.13 

1. 

0.5 

0.25 

0.5 

O.OOOi 

0.13 

0.13 

0.003 
2. 

O.'ofi 

0.6 

0.6 

1. 

4. 

0.6 

0.5 

4. 

0.6 

0.5 

0.6 

0.6 

0.6 

0.12 

0.4 

0.01 

0.001 

0.06 

0.3 

0.06 

0.06 

0.3 

0.6 

0.6 

0.25 

0.6 

0.6 

1. 

4. 

4. 

1.3 

0.3 

4. 

4. 

8. 

0.3         — 


1. 
2. 

-  1.3 
0.6 
2. 

1.3 

-  0.25 
2. 

-  1. 
1.3 
1.5 

0.0005 
0.3 

-  1. 

0.006 
3. 
1. 
1.3 

-  3. 
2. 

-  8. 
1. 
1. 

-  8. 

2. 

-  1. 

-  1.3 

-  1. 
1.5 

-  0.4 

-  2. 

-  o!o2 

-  0.003 

-  0.12 
1. 

-  0.2 

-  0.25 

-  1.3 
2. 

2. 

-  0.6 

-  1.3 

-  1.3 
15. 

-  8. 
-15. 

4. 

-  0.6 
12. 
15. 
12. 

1.3 


DOSE   TABLE 


645 


Remedy 


iGrains  or 


Grams  or  C.e. 


Wine,  pepsin 

quinin 

tar 

tobacco 

white  ash 

wild  cherry 

ferrated 

Xeroform 

Xanthoxyiin 

Xylen  (xylol) 

Xylenol  (ortho-)  salicyl. . . 

Yohimbin 

Zinc,  acetate 

bromid 

chlorid 

dtrate 

cyanid 

ferrocyanid 

hemol 

hypophosphite 

io<tid 

lactate 

oxid 

phosphid 

phosphate 

salicylate 

subgallate 

sulphate 

emetic 

sulphocarbolate 

tannate 

and  potassium  cyanid 
valerianate 


60—240 

240—480 

30—120 

5—30 
60—120 
60—120 
60—120 

5—15 
1—2 
5—15 
2—6 


4. 
15. 
2. 
0.3 
4. 
4. 
4. 

0^ 
0.06 
0.3 
0.13 

0.006 

0.13 

0.06 

0.006 

0.2 

0.006 

0.03 

0.13 

0.03 

0.06 

0.03 

0.06 

0.003 

0.12 

0.03 

0.06 

0.015 

1. 

0.13 

0.06 

0.006 

0.06 


15. 
-30. 

-  8. 

-  2. 

-  8. 

-  8. 

-  8. 

-  1. 

-  0.13 

-  1. 

-  0-4 


0.4 

0.13 

0.02 

0.5 

0.015 

0.24 

0.5 

0-1 

0.13 

0-06 

0.3 

0-015 

0-3 

0-2 

0.25 

0.03 

2. 

0.25 

0.1 

0.06 

0-2 


INDEX  OF  DRUGS 


Classification  of  Drugs  According  to  Their  Therapeutic  Uses 


Drugs  Which  Exercise  No  Definite 
Action  on  Specific  Organs. 

Antiseptics. 

General  principles,   103 

Acetylsalicylic   acid,   160 

Aspirin,  161 

Balsam  of  Peru,  163 

Betanaphthol,   162 

Bismuth  subnitrate,   119 

Boric  acid,  121 

Calcium   dioxid,   143 

Camphor,  194 

Chinosol,   161 

Chlorinated  lime,  134 

Cinnamic  aldehyd,  195 

Corrosive   mercuric   chlorid,   115 

Cresol,  157 

Creosote,   157 

Essential  oils,   184 

Eucalyptol,  195 

Eugenol,  196 

Formaldehyd,  solution  of,  165 

Guaiacol,  157 

Hydrogen   dioxid,   136 

Iodoform,  130 

Magnesium  dioxid,  144 

Menthol,  197 

Mercuric  cyanid,  117 

Methylene  hydrochlorid,  164 

Methyl  salicylate,  197 

Oxygen,  141 

Paraform,  166 

Phenol,   151 

Phenyl  salicylate  (Salol),  160 

Potassium   chlorate,   149 

Potassium  permanganate,  148 

Resorcinol,  158 

Salicylic  acid,   160 

Scarlet  red,  164 

Sodium  borate,  127 

Sodium  diborate,  146 


Sodium   dioxid,   145 
Sodium   salicylate,   160 
Strontium  dioxid,  145 
Thymol,    198 
Thymol  iodid,  133 
Zinc   dioxid,  146 

Astringents. 

General  principles,  199 
Bismuth  subgallate,  206 
Bismuth  subnitrate,  206 
Copper  sulphate,  201 
Lead  acetate,  203 
Rhatany,  211 
Tannic  acid,  209 
White  oak   bark,   211 
Witch-hazel  water,  211 
Xeroform,  207 
Zinc  acetate,  209 
Zinc   chlorid,   203 
Zinc    iodid,   206 
Zinc   oxid,    207 
Zinc  phenolsulphonate,  205 
Zinc    sulphate,    205 

Caustics. 

General  principles,   212 

Alloy    of   potassium    and    sodium, 

216 
Arsenic  trioxid,   230 
Chromium  trioxid,  216 
Lactic  acid,  215 
Nitric  acid,  215 
Osmium   tetroxid,  216 
Potassium   hydroxid,   215 
Silver  nitrate,  217 
Sodium  hydroxid,  216 
Trichloracetic  acid,   214 

Tlcmostatics  and  Styptics. 

General  principles,  250 
Alum,   252 


647 


648 


INDEX   OF   DRUGS 


Hemostatics  and  Styptics — Cont'd. 
Coagulen,   253 
Coagulose,  253 
Epinephrin    eWorld,    solution    of, 

254 
Ferric    subsulphate,    solution    of, 

252 
Gelatin,  253 

Hydrastinin  hydrocMorid,  254 
Iron  chlorld,  solution  of,  251 
Pengliawar  djambl,  251 
Purified  cotton,  251 
Styptic  collodion,  251 
Styptic   cotton,  251 
Stypticin,  254 
Styptol,  254 
Thromboplastin,   253 

Protectives,  Demulcents,  and 
Emollients. 

General  principles,   255 

Acacia,  258 

Collodion,  257 

Exsiccated   calcium   sulphate,   258 

Glycerin,  257 

Gutta-percha,  256 

Paraffin,  257 

Petrolatum,     257 

Kubber,  256 

Solution  of  sodium  silicate,  258 

Tragacanth,  258 

Irritants  and  Counterirritants. 

General  principles,  260 
Ammonia  water,  267 
Cantharides,   266 
Capsicum,  266 
lodin,  262 
Mustard,  265 

Antacids. 

General  principles,  268 
Magnesia,   269 
Magnesium  carbonate,  269 
Milk  of  magnesia,  270 
Precipitated  calcium  carbonate, 

269 
Prepared  chalk,  269 
Sodium  bicarbonate,  270 
Solution      of      calcium      hydroxid 

(lime  water),  269 


Drugs  Which  Act  on  Specific  Organs. 

Bleaching  Agents. 

General  principles,  270 
Barium  dioxid,  274 
Hydrogen   dioxid, 

aqueous  solution  of  (Perhydrol), 

274 
ethereal  solution  of    (Pyrozon), 
274 
Sodium  dioxid,  273 

Preparations  for  the  Mouth 
and  Teeth. 

General  principles,  277 
Abrasives,   291 
Antacids,  291 
Antiseptics,    291 
Astringents,  291 
Correctives,  292 
Mouth  washes,  293 
Stimulants,   292 
Tooth  pastes,  306 
Tooth  powders,   297 
Tooth   soaps,   308 

Local  Anesthetics  and 
Obtundents. 

General   principles,    309 

Acoin  hydrochlorid,  319 

Alypin,  319 

Anesthesin   and   Subcutin,  323 

Chlorbutanol  (Chloretone),  320 

Cocain  hydrochlorid,  312 

Cycloform,  323 

Ether,   326 

Ethyl  chlorid,  326 

Eucain  A  and  B,  319 

Holocain    hydrochlorid,    319 

Methyl  chlorid,  327 

Nervocidin,  320 

Nirvanin,   319 

Novocain,  317 

Orthoform,  322 

Propaesin,  323 

Quinin  and  urea  hydrochlorid,  320 

Stovain,  319 

Tropa-cocain  hydrochlorid,  318 


INDEX   OP   DRUGS 


649 


General  Anesthetics. 

General  principles,  328 
Carbon  tetractlorid,  349 
Chloroform,    347 
Ether,  348 
Ethyl  bromid,  348 
Ethyl  chlorid,  348 
Methyl  chlorid,  349 
Somnoform,    349 

Hypnotics. 

General  principles,  366 
Hj'^drated  chloral,  367 
Paraldehyd,  367 
Sulphonethylmethan     (Trional), 

367 
Sulphonmethan    (Sulphonal)     367 
Veronal,  368 

Anodynes. 

General  principles,  368 
Aconite,   372 
Atropin,   373 
Codein,  370 
Morphin,  369 
Opium,  369 

Sedatives. 

General  principles,  374 
Ammonium   bromid,   375 
Bromural,  375 
Potassium  bromid,  375 
Sodium  bromid,  375 
Valerian,  376 

Cerebral  Stimulants. 

General  principles,  376 
Brandy,  379 
Caffein,   378 
Whisky,  378 
Wine,  red,  379 
Wine,  white,  379 

Stomachics  and  Digestives. 

General  principles,  379 
Columbo,  381 
Dandelion,   381 
Gentian,  381 
Hops,    382 
Pancreatin,  383 


Stomachics  amd  Digestives — Cont'd. 

Pepsin,  382 
Quassia,  382 
Serpentaria,    382 

Emetics. 

General  principles,  383 
Apomorphin  hydrochlorid,  386 
Antimony  and  potassium   tartrate 

(Tartar  emetic),  385 
Copper   sulphate,  385 
Emetin  hydrochlorid,  386 
Ipecac,    386 

Cathartics. 

General    principles,    392 

Aloes,  394 

Cascara  sagrada,  394 

Castor  oil,  395 

Colocynth,   394 

Croton  oil,  395 

Jalap,  394 

Magnesium  sulphate,  396 

Mercurous  chlorid   (Calomel),  397 

Podophyllum,  395 

Potassium  citrate,  396 

Ehubarb,    394 

Senna,  395 

Sodium  phosphate,  395 

Sodium  sulphate,  396 

Sulphur,   397 

Circulatory  Stimulants  and 
Depressants. 
General  principles,  399 
Amyl  nitrite,  402 
Digitalis,  401 

Nitroglycerin,  spirit  of,  402 
Strophantus,  401 
Strychnin  sulphate,  402 
Suprarenal  glands,  desiccated,  403 

Bespiratory  Stimulants  and 

Depressants. 

General  principles,  404 
Tonics. 

General   principles,   406 

Arsenic,  409 

Calcium,  411 

Fluorin,  411 

Iron,   407 

Phosphorus,   410 


650 


INDEX   OF   DRUGS 


Alteratives. 

General  principles,  412 
lodids,   414 
Mercury  salts,  415 

SicUogogues  and  Antisialogogues. 

General    principles,    419 
Atropin  sulphate,  421 
Pilocarpin  hydrochlorid,  420 

Diaphoretics. 

General  principles,  421 

Diuretics. 

General  principles,  423 
Thcobromin  sodium  salicylate,  424 


Uric  Acid  Solvents. 

General  principles,  424 

Atophan,  430 

Hexamethylene  (Urotropin),  430 

Lithium   carbonate,   430 

Lithium  citrate,  430 

Lithium    salicylate,    430 

Antipyretics. 

General  principles,  431 

Acetanilid,   435 

Acetphenetidin    (Phenacetin),  435 

Acetylsalicylic  acid  (Aspirin),  434 

Antipyrin,   434 

Quinin  sulphate,  433 

Organo  and  Serum  Therapy. 
General  principles,  436 


GENERAL  INDEX 


Abrasives,    291 
Absorbents,  251 
Acacia,  258 

mucilage  of,  258 
A.  C.  E.  mixture,  349 
Acetanilid,  435 
Acetocaustin,  215 
Acetozon,  147 
Acetphenetedin,  435 
Acid,  acetylsalicylic,  160 
arsenous,   230 
benzoic,   159 
boric,   121 

ointment  of,  121 
carbolic,   151 
china,  428 
chromic,  216 
gallic,  210 
hydrochloric,  122 

diluted,  122 
lactic,  215 
muriatic,  122 
nitric,    122,   215 

diluted,  122 
nitrohydrochloric,    122 

diluted,  122 
osmic,  216 
phenic,  151 
phenolsulfonic,   124 
picric,  163 
phosphoric,   126 

diluted,  126 
salicylic,   160 
sulphoearbolic,    124 
sulphuric,   123 
aromatic,  123 
diluted,  123 
tannic,  209,  255 
trichloracetic,  214 
uric,    424 
Acids.    120 


Acoin,  319 
Aconite,  372 

tincture  of,  372 
Actol,  228 
Adrenalin,  527 
Agents,  bleaching,  270 

coloring  and  flavoring,   78 
Aids,  diagnostic,  603 
Albargin,   228 
Albargol,  228 
Alcohol,  ethyl,   182 

methyl,   182 
Alkalies,  126 
Aloes,  394 
Alphozon,  147 
Alteratives,  412 
Alum,  252 
burnt,  202 
exsiccated,  252 
Alumnol,  207 
Alveolar  process,  anatomic  structure 

of,  543 
Alypin,   319 
Aminoform,   166 
Ammonium  bifluorid,  429 

bromid,  375 
Amyl  nitrate,  402 
Anesthesia: 
insufflation,  of  the  upper  auterior 

teeth,  563 
local,  514 

about  the  mouth,  576 
history,  514 

means  of  producing,  518 
pressure,  565 
symptoms  of,  353 
Anesthesin,  323 
Anesthetics,  choice  of,  358 
general,   328 

statistics   of,  352 
local,  309,   530 


651 


652 


GENERAL   INDEX 


Anesthetics,  local — Cont  'd 
chemic  relationship,  323 

insoluble,   322 
physiologic  action  of,  519 
side  and  after  effect  in  relation 
to  penal  code,  579 
refrigerants,  local,  326 
Anesthetizing  the  pulp,  569 
Anesthile,  327 
Anestol,  327 
Anilin   dyes,   164 
Anion,  111 
Anodynes,  368 
Antacids,  268,  291 
Antifebrin,  435 
Antiformin,  134 
Antimony    and    potassium    tartrate, 

385 
Antipyretics,  431 
Antipyrin,  434 
Antiseptic  solution,  121 
Antiseptics,   103 

of    aromatic    series,    150 

of  marsh  gas  series,  165 
Antisialogognes,  419 
Antitoxins,  438 
Aperients,    392 

Apomorphin  hydrochlorid,  386 
Aqua  regia,  122 
Argentamin,  228 
Argentol,  229 
Argonin,  228 
Argyria,  223 
Argyrol,  229 
Aristol,   133 
Arkovy's  mixture,  156 
Armamentarium,  hj'podermic,  536 
Arsenic,   409 

and  mercury  iodid,  solution  of,  23 1 

trioxid,  230 

trisulphid,  230 
Artificial   dentin,   208 
Aspirin,   160,  434 
Astringents,   199,   291 

metallic,  201 

vegetable,  209 


Atophan,  430 
Atoxyl  arsenate,  416 
Atropin  sulphate,  373,  421 
Auramin,  164 
Auripigment,   230 

Balsam  del  deserto,  163 
Balsam,  Friars',  257 

of  Peru,  163 

Turlington's,   257 
Barium  sulphid,  217 
Benzoin,  compound  tincture  of,  257 
Betanaphthol,  162 
Biogen,   144 
Bismuth  paste,  483 

subgallate,  206 

subnitrate,  119,  206 

tribromphenolate,  119,  207 
Blackberry,   211 
Black's  1-2-3,   156 
Bleaching  agents,  270 

processes,  273 
Blue  stone,  201 
Bone  plombe,  478 
Borax,  127 
Borite,  143 
Borneol,  194 
Brandy,  379 
Bromural,  375 
Buckthorn,  394 

Burnett's  disinfecting  fluid,   204 
Burns,  solution  for,  164 
•  Butylchoral  hydrate,  367 

Caffein,  378 

citrated,  378 

effervescent  citrated,  378 
Calcination,  91 
Calcium,  411 

carbonate,  precipitated,  269 

eWorld,  253 

dioxid,  143 

hydroxid,   solution   of,    269 

lactate,    253 

sulphate,  exsiccated,  258 
Calomel,  397 

vegetable,  395 


GENERAL   INDEX 


653 


Campho-phenique,  155 
Camphor,  194 
Cantharides,    26G      .^i.'   .• 
Caoutchouc,  256        v    .    ,i  ;. 
Capsicum,  265  ,    ;, 

Capsules,  93 

Carbon    tetrachlorid,    319 
Carvon,  195 
Cascara  sagrada,  394 
Cataplasms,  476 
Catechu,  212 
Cathartics,  392 

saline,  395 

vegetable,  394 
Cation,  111 

dry,  215 

liquid,    214 
Caustic,   iodin,    265 

iodin,  Churchill's,  265 

mitigated,  218 
Caustics,  212 

Cavity   varnish,   antiseptic,   162 
Cellulo-aceton,  259 
Cement,  Sorel's,  207 
Cerates,  93 
Chalk,  precipitated,  299 

prepared,  269 
Charcoal,  302 
Chinosol,   161 
Choral  hydrate,  367 
Chlorbutanol,   320 
Chloroform,  347 
Chloro-percha,  183,  259 
Chloretone,  320 
Chromic  trioxid,  216,   255 
Cinnamic  aldehyd,  195 
Citarin,  430 

Cleanser,  hand,  oxygenated,  148 
Coagulen,  253 
Coagulose,  253 
Cocoa,  fluidextract  of,  314 

wine  of,  314 
Cocain   hydrochlorid,   312,   530 
Cocain,  oleate  of,  314 

phenate,  314 
Cocainism.  316 


Codein  phosphate,  370 

Collargol,  228 

Collodion,   93,   257  .  ,.  .   ,   : 

flexible,  257 

styptic,  251 
Colocynth,  394 
Columbo,  381 
Comminution,  90 
Condy's  fluid,  148 
Confections,  94 
Copper  sulphate,  201,  385 
Correctives,  292 
Coryl,  524 
Cotarnin  hydrochlorid,  254 

phthalate,    254 
Cotton,  purified,  251 

styptic,   251 
Counterirritants,  260 
Cream,  dentist's  hand,  260 
Cream  of  tartar,  396 
Creosote,   157 
Cresol,  157 

compound  solution  of,  158 

formothymol,   167 
Croton,  chloral  hydrate,  367 
Cuprol,   202 
Cuttlefish  bone,  302 
Cycloform,  323 
Cystogen,   166 

Dandelion,  381 
Decantation,  90 
Decoctions,  94 
Demulcents,  255 
Dentinagen,   208 
Dentin,  artificial,  208 

hypersensitive,  treatment  of,  574 
Depressants,    circulatory,   399 

respiratory,  404 
Dermatol,  206 
Desiccation,   90 
Diaphoretics,  421 
Digestives,  379 
Digitalis,  401 
Dimazon,   165 
Discs,  devitalizing,  249 


654 


GENERAL   INDEX 


Disinfectants,  103 

Disinfection  of  rooms,   169 

Displacement,   92 

Dissociation,  electrolytic,   110 

Distillation,    90 

Diuretics,  423 

Diuretin,   424 

Dose,  41 

Dose  table,  606 

Doses,  average,  of  dental  drugs,  100 

Drastics,  392 

Drops,  Jesuits',  257 

Drugs,  31 

action  of,  37 

organic  constituents  of,  88 
Dry  mouth,   421 

£au  de  Botot,  295 

Ecgonin,  324 

Electro-sterilization,  484 

Elixirs,  94 

Elixir   of   vitriol,   123 

Emetics,  383 

Emetin,  19,  386 

Emollients,  255 

Emulsions,  94 

Epinephrin,   403,    505 

Epineplirin  chlorid,  solution  of,   254 

Equivalent,   thermametric,   605 

Ergot,   254 

Escharotics,   212 

Ether,   326,   348 

Ethyl  bromid,  348 

carbamate,  367 

chlorid,  326,  348 

administration  of,  353 
Eucain,  319 
Eucalyptol,   195 
Eugenol,  196 
Europhen,  133 
Evacuants,  395 
Evaporation,  91 
Expression,  91 
Exsiccation,  91 
Extracts,  94 

fluid,  94 


Extract,   Goulard's,   203 
Ferratin,  407 
Ferripyrin,   252 
Ferropyrin,    252 
Fibers,    devitalizing,   249 
Fibrolysin,  418 
Figs,   476 
Filtration,  91 
Finsen  light,  464 

Fluid,  Burnett's  disinfecting,  204 
sterilizing,  for  instruments,  128 
Fluorin,  411 
Formagen,   167 

Formaldehyd,   solution   of,   165 
Formalin,   165 
Formalin,  dermatitis,  168 
Formamint,   166 
Formin,  166 
Formocresol,   172,   183 
Formol,  165 
Frangula,  394 

Gangrene  of  pulp,  174 
Gargles,  94 
Gelatin,  253 

General  anesthesia,  treatment  of  ac- 
cidents, 359 
Gentian,  381 
Germicides,  103 
Glands,   suprarenal,  403 
Glass,  liquid,   258 
Glycerin,  257 

Glycerite  of  boroglycerin,  121 
Glycerite  of  phenol,   152 
Glycerites,  94 
Glycerol,  257 
Golden  moss,  251 
Golden  seal,  254 
Guaiacol,  157 
Guaiacol  carbonate,  157 
Gutta-percha,  256 

Halogens,    129 
Heat  and  cold,  474 
Heavy  metals,  salts  of,  108 
Hemorrhage,   250 


GENERAL  INDEX 


655 


Hemostatics,  250 

Hermophenyl,  118 

Hexamethylenamin,  166,  430 

Holocain,  319 

Honeys,  94  ... 

Hops,   382 

Hydiagogues,  392 

Hydrastinin   hydrocblorid,    254 

Hydrated  chloral,  367 

Hydrogen   dioxid,  255 
solution  of,  136 

Hydronaphthol,  162 

Hyperemia,  artificial,  442 
methods  of  inducing,  448 
therapeutic   indications,   451 

Hypersensitive    dentine,     treatment 
of,  574 

Hypnotics,  366 

latrochemistry,  53 
lotromechanics,  53 
lotrophysics,   53 
lotropsycliics,  53 
Immunity,  437 
Incompatibilities,   74 
Infusions,  94 
Injections,  94 
Injection,  extra  oral,  563 

infra-orbital,  562 

into  the  mandibular  nerve,  555 

intraosseous,  553 

peridental,  551 

subperiosteal,  547 

technique  of,  542 
lodids,  414 
lodin,   262 

compound  solution  of,  263 

Talbot's,  265 

tincture   of,   263 
Iodoform,  130 

bone  plombe,  133 

paste,  133 
lodo-glycerol,  Talbot's,  265 
lodol,  132 

Tonic  medication,  488 
Ions.  Ill 


Ipecac,  19,  386 

Ipecac  and  opium,  powder  of,  370 

Iron,  407 

carbonate,   408 

chlorid,  solution  of,  251 

masked,  409 

oxid,  saccharated,  408 

perchlorid,  solution  of,  252 

subsulphate,  252 

subsulphate,   solution   of,  252 
Irritants,  260 
Itrol,  228 

Jaborandi,   420 
Jalap,  394 
Juices,  94 

Kalium-natrium,   216 
Kava-kava,  327 
Kelene,  524 
Keys-all,  162 
Kino,  211 
Krameria,  211 
Kresamin,  158 
Kryofin,  432 

Largin,  228 

Laudanum,  369 

Laughing  gas,  332 

Law,  national  narcotic,  97 

Laxatives,  392 

Lead  acetate,  203 

Lead,  subacetate,  solution  of,  203 

sugar  of,  203 
Light  therapy,  463 
Lime,   chlorinated,  134 
Liniments,  94 
Liniment,   ammonia,   267 

dental,   Hoff's,   267 

iodin,  263 
Liquores,  95 
Lithium    carbonate,    430 

citrate,  430 

salicylate,  430 
Logwood,  211 
Lotions,  94 


656 


GENERAL   INDEX 


Lunar  caustic,   218 
Lycetol,  431 
Lysoform,   166 
Lysol,   158 

Maceration,  91 
Magnesia,  269 

milk  of,  270 
Magnesium  carbonate,  269,  301 

citrate,  solution  of,  396 

dioxid,    144 

oxid,  269 

sulphate,  396 
Mandrake,  395 
Marsh  gas,  165 
Mass,  blue,  397 

Valet's,  398 
Massage,  458 
Masses,  94 
Masticol,  260 
Menthol,  197 
Mercurol,   118 
Mercurous  chlorid,  397 
Mercury,  ammoniated,  119 

bichlorid,  115 

cyanid,  117 

iodid,  red,  118 

iodid,  yellow,  118 

mass  of,  397 

oxid,  red,  118 

oxid,  yellow,  118 

salts,  415 

subsulphate,  386 

succinimid,  417 
Metacresol,  158 
Metallic  salts,  action  of.  111 
Methethyl,  327 
Methods,  pharmaceutic,   90 
Methylene   blue,    164 

violet,  164 

yellow,   164 
Methyl  chlorid,  327,  349 

salicylate,  197 
^fixtures.  94 
Monk's  hood,  372 
Monochlorphenol,  15fi 


Morphin    acetate,    369 

Morphin,  compound   powder  of,   370 

hydrochlorid,  370 

sulphate,  370 
Mouth  wash,  alkaline,  295 

antiseptic,   294 

betanaphthol,   162 

chinosol,  297 

colors,  for,  297 

hydrogen  dioxid,  297 

Miller's,  296 

Pickerill's,  296 

Pruyn's,   295 

resorcinol,  296 

Eomer's,  296 

saccharin,  296 
Mouth  washes,  293 
Mucilages,  94  ^ 

Mustard,  265 
Myrrh,  24,  160 
Myrtol,   198 

Narcotic  law,  national,  97 

Narcotics,  328 

Narcotile,  524 

Nargol,  229 

Necrosis  of  pulp,  172 

Neosalvarsan,  417 

Nervocidin,  320 

Neurocain,  314 

Nioform,   133 

Nirvanin,  319 

Nitrogen  protoxid,  332 

Nitroglycerin,    spirit    of,   402 

Nitrous  oxid,  332 

administration   of,   335 
physiologic  action  of,  334 

Novocain,  317,  530 

Oak  bark,  white,  211 
Obtundents,  309,  317 
Oil,  bay,  193 

betula,  190 

cajuput,  191 

cananga,  194 

caraway,  191 


GENERAL   INDEX 


657 


Oil— Cont'd 

cassia,    191 

castor,  395 

cinnamon,  29,  191 

clove,  18,  29,  192 

croton,  395 

essential,  29,  184 

eucalyptus,  192 

gaultheria,  193 

mustard,  volatile,  193 

myrcia,   193 

of  smoke,  157 

of  vitriol,  123 

peppermint,   29,   193 

sweet   birch,   190 

teaberry,  193 

thyme,  194 

wintergreen,  193 

ylang  ylang,  194 
Ointment,  compound  resorcinol,  159 

phenol,  152 
Ointments,   94 
Oleates,  94 
Oleoresins,  95 
Opium,   369 

powdered,  369 

tincture  of,  369 

tincture  of,  camphorated,  369 

tincture  of,  deodorized,  369 
Opsonins,  437 
Oral  hygiene,  277 
Organic  drugs,  constituents  of,  88 
Organo-therapy,  436 
Orexin  hydrochlorid,  382 
Orpiment,  230 
Orthocresol,  158 
Orthoform,  322 

new,  322 
Osmium  tetroxid,  216 
Oxone,  136 
Oxymethylen,  166 
Oxygen,  141 

Oyster  shells,  prepared,  300 
Ozone,   135 


Paint,  iodin,  Carson's,  265 
Pancreatin,  383 
Papain,  383 
Papers,  95 
Papoid,  383 
Paracresol,  158 
Paraffin,  257 
Paraform,  166 
Paraformaldehyd,  166 
Paraldehyd,  367 
Paranephrin,  528 
Paregoric,  369 
Paste,  depillatory,  217 

desensitizing,   Buckley's,   167 

devitalizing,  249 

pulp  capping,  197 

pulp  mummifying,  184 

Scheuer's  root  filling,  184 
Pellidol,  165 
Penghawar  Djambi,  251 
Pental,   333 
Pepsin,  382 
Peraquin,  136 
Percolation,  92 
Pergenol,  147 
Perhydrol,  136,  255 
Petrolatum,  257 
Petrolatum  liquid,  398 
Pharmacology,  31 
Pharmaco-dynamics,  31 
Pharmacopeia,  86 
Phenacetin,  435 
Phenol,  151 

camphorated,  155 

coefficient,   105 

glycerite  of,  152 

ointment   of,   152 

sodique,  106,  155 
Phenolphthalein,  398 
Phenyform,  166 
Phenyl  salicylate,   160 
Phosphorus,  410 
Pills,  95 
Pilocarpin  hydrochlorid,  420 

nitrate,  421 
Piperazin,   431 


658. 


GENERAL   IXDEX 


Plaster,  mustard,  266 

Plasters,  95,  259 

Piatt's   chlorides,   106 

Plugging  bone  cavities,  478 

Podophyllum,   395 

Poisoning,  acute,  treatment  of,  595 

Potash,  caustic,  215 

Potassium  arsenite,  solution  of,  231 

bitartrate,  396 

bromid,  375 

chlorate,  149 

citrate  396 

hydroxid,  215 

iodid,  415 
ointment  of,  415 

permanganate,  148,  254 
Potassium       and       sodium       alloy, 

Shreier's,  216 
Potassium  and  sodium  tartrate,  396 
Poultices,  95,  476 
Powders,  95 
Powder,  compound  effervescing,  397 

Dover's,  370 
"Monsel's,  252 

Seidlitz',  397 

styptic  dusting,  210 

TuUy's,  370 
Precipitation,  92 
Preparations,  pharmaceutic,  93 
Prescription  writing,  63 

coloring  and  flavoring  agents,  78 

construction,  69 

dose,  41 

estimation  of  quantities,  72 

metric,  68 

metric  system,  80 

pharmaceutic  methods,  90 

pharmaceutic   preparations,   93 

pharmacopeia,  86 

signs  and  numerals,  71 

terms  used  in,  70 
Propaesin,  323 
Protargol,  228 
Protectives,   255 

Pulp,  diagnosis  of  diseases  of,  by  the 
electric  current,  585 


Pumice   stone,   300 

Pyoktanin,  164 

Pyorrhea,  treatment  of,  by  emetin. 

387 
Pyrozon,  137,  255 

Quassia,  382 

Quinin,   18 

Quinin   and   urea    hydrochlorid,    320 

Quinin  sulphate,  433 

Kadio-active  substances,  467 

Kesins,  95 

Kemedy,  Eobinson's,  216 

Resorcinol,  158 

Resorcinol  ointment,  compound,  159 

Khatany,  211 

Rhubarb,  394 

Eobinson's  remedy,  216 

Koot  canal  filling  materials,  183 

Root  canals,  infected,  treatment  of, 

171 
Rosin,  carbolized,   259 
Rubber,  256 

Saccharin,  108 

Sal  Alembroth,  116 

Saliva,  278 

examination  of,  for  mercury,  416 
Salol,  160 
Salt,  English  smelling,   268 

Rochelle,  396 
Salvarsan,  417 
Sandarac,  259 
Sandarach,  233 
Sapodermin,  118 
Scarlet  red,  Biebrich,  164 
Sedatives,  374 
Senna,  395 
Serpentaria,  382 
Serum  therapy,  438 
Sialogogues,  419 
Sidonal,  431 
Silex,  liquid,  258 
Silver  acetate,  228 

citrate.   228  '        " 


GENERAL   INDEX 


€59 


Silver  lactate,  228 

nitrate,  217 
Silverol,  229 

Snake  root,  Virginia,  382 
Soap,  liquid,  128 
Soaps,  128,  302 
Soda,  caustic,  216 

chlorinated,  solution  of,  134 
Sodium  bicarbonate,  270 

borate,  127 

bromid,  375 

chlorid,  107 

diborate,  146 

dioxid,  145 

ethylate,  solution  of,  215 

hydroxid,  216 

iodid,  415 

perborate,  146 

phenolate,  solution  of,  155 

phosphate,  395 

salicylate,  160 

silicate,  solution  of,  258 

sulphate,  396 
Solution,  anesthetic,  preparation  of, 
533 

Dobell's,  128 

Donovan's,  231 

Fowler's,  231 

iodin,  Talbot's,  265 

iodin.  Younger 's,  265 

Labarraque 's,  134 

local  anesthetic,  317 

Lugol's,  263 

Monsel's,   252 
Solutions,  92,  95 
Somnoform,   349 
Spirits,  95 
Steresol,  260 
Stimulants,  292 

cerebral,  376 

circulatory,  399 

respiratory,  404 
Stomachics,  379 
Stovain,  319 
Strontium  dioxid,  145 


Strophauthus,  401 
Strychnin  nitrate,  402 

sulphate,  402 
Styptics,  250 
Stypticin,  254 
Styptogan,   254 
Styptol,  254 
Subcutin,  323 
Sublamin,   118 
Sublimate,  corrosive,  115 
Sublimation,  92 

Suction  cup,  treatment  with  the,  453 
Sulfur,  397 

washed,  397 
Sul phonal,  367 
Sulphonethylmethan,  367 
Sulphonmethan,  367 
Sumach,  211 
Suppositories,  96 
Suprarenalin,  528 
Suprarenin,  527 
Syrups,  96 

Talcum  powder,  oxygenated,  147 

Tamarinds,  395 

Tanacol,  211 

Tannalbin,  211 

Tannigen,  211 

Tannin,  209 

Tannoform,   211 

Tannopin,  211 

Tartar  emetic,  385 

Tartar  solvent,  429 

Terms,  therapeutic,  glossary   of,  599 

Theobromin  sodium  salicylate,  424 

Thymol,  198 

camphene,  156 

iodid,   133 

iodid,  solution  of,  265 

phenolated,   156 
Thymotal,  199 
Tinctures,  96 
Tonics,  406 
Tooth  paste,  306 

Miller's,  307  I 


660 


GENERAL  INDEX 


Tooth  paste — Cont'd 

Kolynos,  308 

Saline,  308 
Tooth  powdei,  297 

colors  for,  304 

Cook's,  306 

Fitzgerald's,  304 

Harlan's,  305 

Lasar's,  305 

Miller's,  305 

oxydizing,  305 

Pedley's,  306 

Philadelphia    Dental    Dispensary, 
305 

red,  306 

Vegetol,  306 

violet,  306 
Tooth  pulp,  decomposition  of,  172 
Tooth  soap,  308 

Austrian,  308 

Bergmann's,  308 

Kobert's,  309 

thymol,  309 
Tragacanth,  258 
Tricresol,  157 
Trinitrophenol,  163 
Trional,   367 
Trioximethylen,   166 
Triturations,  92,  96 
Troches,  96 
Turpeth  mineral,  386 

Urethan,  367 
Uric  acid  solvents,  424 
Urosin,  357 
Urotropin,  166 

Valerian,  376 

Validol,  376 

Varnish,  antiseptic  cavity,  162 

sandarac,  259 

shellac,  259 

wound,    260 


Vaselin,  257 

Vermillion,  417 
Veroform,  166 
Veronal,  368 
Vibration,  460 
Vinegars,  97 
Vioform,  133 
Vitriol,  blue,  201 
white,  205 

Wash,  yellow,  116 

Waters,  97 

Water,  ammonia,  267 

ammonia,  stronger,  267 

lime,   269 

witch-hazel,  211 
Weights  and  measures,  79 
Wines,  97 
Wine,  red,  379 

white,  379 
Witch-hazel  extract,  211 
Whisky,  378 

Xanthin,  422 
Xanthoprotein,  225 
Xeroform,  119,  207 

Yellow  wash,  116 
Yohimbin,  327 

Zinc  acetate,  209 

cement,  207 

chlorid,  203,  255 

dioxid,   146 

iodid,  206 

oxid,   207 

phenolsulphonate,    152,    205 

sozo-iodolate,   209 

subgallate,  206 

sulphate,  205 

sulphocarbolate,  152,  205 
Zineol,  209 


UNIVERSITY 


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